1. Gynecologic Pathology as it Relates to General Surgery
Lily Shamsnia, MD
Department of Obstetrics and Gynecology
Tulane University School of Medicine
There are many gynecologic disorders that mimic those of general surgery,
Includes disorders of many organ systems:
Urogenital
Gynecologic
Vascular
Pulmonary
Abdominal pain may be infectious, inflammatory, anatomic or neoplastic.

2. GYN vs. General Surgery
Many Gynecologic disorders mimic those of General Surgery, especially regarding etiology of acute and chronic pelvic pain, as well as the diagnosis/treatment of an acute abdomen.
Abdominal pain may be infectious, inflammatory, anatomic or neoplastic
Includes disorders of many organ systems:
Urogenital
Gynecologic
Vascular
Pulmonary
Abdominal pain may be infectious, inflammatory, anatomic or neoplastic.

3. Acute right lower abdominal pain in women of reproductive age: Clinical clues Hatipoglu, et. al
290 female patients presenting to ED with acute abdominal pain
Patient (n=290), n (%)
Age (yr)
Acute appendicitis
224 (77.2)
21 (12-24)
Perforated appendicitis
29 (10)
22 (14-42)
Ovarian cyst rupture
21 (7.2)
24 (15-38)
Corpus hemorrhagic cyst rupture
12 (4.2)
21 (13-55)
Adnexal Torsion
4 (1.4)
24 (19-30)
290 female patients presenting to ED with acute onset abdominal pain
Ref: Sinan Hatipoglu, Filiz Hatipoglu, Ruslan Abdullayev .Acute right lower abdominal pain in women of reproductive age: Clinical clues
World J Gastroenterol 2014 April 14; 20(14):

4. Alvarado Score
Alvarado Score
Point Value
Abdominal pain migrating to RLQ 1
Anorexia or urine ketone
Nausea or vomiting
Tenderness in RLQ 2
Rebound tenderness
Fever
Leukocytosis
Neutrophilia
Scoring:
0-4: unlikely appendicitis
5-6: consistent with
dx of appendicitis
7-8: probable appendicitis
9-10: very probable
appendicitis
Symptoms/signs of appendicitis also similar to those of GYN emergencies
Symptoms/signs of appendicitis similar to many GYN disorders

5. Approach to Acute Abdominal/Pelvic pain in a Female
History and physical exam
Bimanual and speculum exam
UPT/ serum bHCG
Cervical cultures
Radiologic studies
History of prior pelvic surgeries ie hysterectomy, ovarian surgery, etc; STD history, LMP, contraceptive use.
CMT is taught to be pathognomonic for PID- but any disease causing pelvic inflammation can cause CMT

6. DDx pelvic pain of GYN origin
Pelvic Inflammatory Disease (PID)
Tubo-ovarian Abscess (TOA)
Endometriosis
Ruptured or Hemorrhagic Ovarian Cyst
Adnexal Torsion
Uterine Fibroids
Ectopic Pregnancy

7. Pelvic Inflammatory Disease (PID)
Inflammation and infection of the upper female genital tract, including the cervix, fallopian tubes, and uterus.
Peritonitis also may be present.
Early diagnosis and treatment to prevent long-term morbidity is key.
An episode of PID can cause recurrent/chronic PID, chronic pelvic pain, ectopic pregnancy, infertility.

8. PID Ascending infection from the lower genital tract.
Neisseria gonorrhoeae,
Chlamydia trachomatics,
Diptheroids,
Gardenella vaginalis,
Mycoplasma genitalium,
Bacteroides,
Anaerobes,
Streptococci
> 50% cases have more than one organism isolated
Women with LMP within 7 days of presentation of pain- 5 x more likely to have PID than appendicitis.

9. PID
Symptoms/signs mimic that of appendicitis due peritoneal irritation and can often be vague/ misleading
Diagnosis missed in up to 35% of patients.
Mucopurulant cervical/vaginal discharge is present with PID

10. PID- CDC Diagnostic Criteria
Minimal Dx Criteria-
Pelvic or lower abdominal pain AND
CMT OR uterine tenderness OR adnexal tenderness
Additional criteria:
oral temperature >101 F
Cervical/vaginal mucopurulent discharge
WBC on microscopy of vaginal secretions
Elevated ESR
Elevated CSR
Documented gonorrhea/chlamydia cervical infection
Most specific
Endometrial biopsy showing endometritis
Radiographic imaging showing thickened fluid filled tubes indicative of infection
Laparoscopic abnormalities consistent with PID

11. PID Ultrasound CT scan Transvaginal preferable
Uterine enlargement/thickened endometrium
Ovarian enlargement (reactive inflammation)
Edematous distended fallopian tubes with hypervascularity on Doppler US
CT scan
Pelvic inflammation and fat stranding, indistinct tissue planes.
MRI can be useful and more accurate, with high sensitivity for pyosalpinx ( hyperintesne tubular structures on T2 weighted images); not cost effective and not first line.
US of appendicitis- noncompressible, non-peristaltic tubular structure arising from cecum base, measuring > 6 cm
CT appendificits: periappendiceal fat with fat stranding, enlarged appendix that does not fill with contrast, cecal/appendicieal wall thickening.
Patients with acute appendicitis > TOA more likely to have enlarged appendix > 6 cm, thickened appendiceal wall > 3 mm, periappendiceal fluid collection, cecal wall thickening, pericecal fat stranding on CT

12. PID- Ultrasound
Ovary
Dilated fallopian tube

13. PID- CT scan Right side , normal
Left side, thickened/inflamed tubal wall

14. PID- treatment
Outpatient: Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO BID x 14 days +/- Metronidazole 500 mg PO BID x 14 days
Inpatient:
A: Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg PO/IV q 12 hours
B: Ampicillin/Sulbactam 3 g IV q 6 hours PLUS Doxycycline 100 mg PO/IV q 12 hours
Diagnostic laparoscopy vs exploratory laparotomy- If diagnosis is unclear ( i.e. PID vs appendicitis vs TOA), or no improvement with antibiotics
Criteria for hospitalization- surgical emergencies ( ie appendicitis) cant be ruled out, pregnancy, cannot tolerate PO regime, not responding to oral antibiotics, severe illness ie high fever/n/v, presence of TOA
If dx laparoscopy and PID is seen- pelvic irrigation and continued antibiotics. Can CONSIDER appendectomy to prevent diagnostic confusion in the future, but this remains controversial ie in the setting of purulent PID, appendectomy is not an appropriate course of action.

15. PID on laparoscopy

16. Fitz High Curtis
Occurs with pelvic inflammation of PID spreads to right upper quadrant via right paracolic gutter and involves peritoneal surface of liver.
Violin-string adhesions, typically encountered during laparoscopy, typically laparoscopic cholecystectomy
When present during lap chole- care should be taken while retracting triangle of Calot as adhesions of the liver to peritoneal surfaces can cause liver lacerations in not freed before attempting retraction.

17. Fitz High Curtis

18. Tubo-Ovarian Abscess (TOA)
35% of women with PID, years old, small percentage postmenopausal.
2/3 are unilateral- may lead to misdiagnosis of appendicitis if on right side.
Initial insult to the female genital tract- inoculation and destruction of fallopian tube epithelium  a purulent exudate with low oxygen environment favorable for anaerobic organisms.
Inflammatory response induces edema, ischemia, and necrosis of fallopian tube.
Usually years old, small percentage postmenopausal.
Risks similar to PID- multiple sexual partners, low SES statis, immunosuppression, HIV, no contraceptive use.
2/3 are unilateral- may lead to misdiagnosis of appendicitis if on right side.

19. TOA
Surrounding structures may become involved in the expanding inflammation and walled off abscess, including ovary, round ligament, broad ligament, contralateral fallopian tube and ovary, appendix, bowel, and bladder.
With expansion, rupture of TOA can occur.
TOAs can be the result of non- gynecologic disease, including diverticulitis, appendicitis, inflammatory bowel disease, and surgery.

20. TOA
Polymicrobial:
E. coli,
Bacteroides
Peptostreptococcus
Enterococcus
Klebsiella
Staphylococcus
Streptococcus
H. influenza.
N. gonorrhoeae and C. trachomatis are rarely cultured from TOAs.
Anaerobic bacteria are present in % of TOA cultures.

21. TOA Lower abdominal pain (acute vs chronic), nausea/vomiting
+/- fevers/chills- up to 50% of patients are afebrile
If bowel is involved- anorexia/diarrhea
Leukocytosis- present but not reliable indicator
Palpable abdominal/pelvic mass, rebound tenderness/guarding
CMT, mucopurulent discharge, vaginal discharge/abnormal bleeding

22. TOA- Imaging Ultrasound- sensitivity > 90% for diagnosis.
Transabdominal- larger field of view for identifying adnexal masses.
Transvaginal- detailed view of pelvic anatomy and vasculatyure.
Appear complex, multilocular, cystic with thickened walls and internal echoes/debris.
Tubal and ovarian architecture disordered with destruction of planes between the ovary and developing abscess.
Cogwheel sign- thickening of endosalpingeal folds.

23. TOA- Imaging
CT scanning if diagnosis is unclear- septated tubular structure with thickened walls.
Hydronephrosis/hydroureter may be seen when surrounding tissue is involved with the inflammation.
Gas bubbles within the fluid collection- highly specific for TOA
TOA vs. appendicitis- TOA was highly associated with appearance of abnormal ovary, peri-ovarian fat stranding, small bowel and recto-sigmoid thickening, and free fluid in the pelvis.

24. TOA on US

25. TOA on CT

26. Appendicitis on US
US of appendicitis- non-compressible, non-peristaltic tubular structure arising from cecum base, measuring > 6 cm

27. Appendicitis- CT Imaging
CT appendicitis: periappendiceal fat with fat stranding, enlarged appendix that does not fill with contrast, cecal/appendicieal wall thickening.
Patients with acute appendicitis > TOA more likely to have enlarged appendix > 6 cm, thickened appendiceal wall > 3 mm, periappendiceal fluid collection, cecal wall thickening, pericecal fat stranding on CT

28. TOA- Treatment Treat infection and preserve fertility
Mainstay of therapy is antibiotics +/- additional drainage procedures ( image guided transabdominal or transvaginal approach)
Parenteral antibiotics until 48 hours afebrile; continuation of oral antibiotics for 14 days
Patients treated with only antibiotics- longer hospital stays, longer duration of fever, require surgical intervention more frequently than those who undergo a drainage procedure initially.
Appropriate response- relief of pain, normalization of fevers, decrease in leukocytosis
Drainage- via image guided transabdominal or transvaginal approach

29. TOA- Surgical Treatment
1) Concern for alternative surgical emergency i.e. appendicitis, cholecystitis, bowel obstruction/perforation
2) Failure of clinical response after hours of medical therapy
3) Intra-abdominal rupture of TOA- emergent surgery warranted due to hemodynamic instability, sepsis, multi-system organ failure
Historically- aggressive surgical therapy was with primary treatment for TOA, from adnexectomy to TAHBSO.
Due to high rate of bowel injury and concern for future fertility, surgical management is more conservative.
If surgical approach is warranted, complete inspection of abdominal cavity is necessary- uterus, both ovaries and tubes, appendix, sigmoid, upper abdomen.
Cultures of abscess fluid should be taken, and pelvis should be copiously irrigated. Consider placement of closed suction drains.
If frank contamination is encountered- leave skin and subcutaneous tissue open to close by secondary intention.

30. TOA on laparoscopy

31. Endometriosis
Defined as presence of endometrial glands and stroma outside uterine cavity.
Most accepted theory- development is retrograde menstruation. Other theories include coelemic metaplasia of endometrial tissue with lymphatic spread, and transformation of embryonic rests.

32. Endometriosis
Prevalence % in general population; up to 50% in infertile women
60% of women with dysmenorrhea, 87% of women with CPP
Symptoms- dysmenorrhea, dyspareunia, CPP, pain with ovulation, micturition, defection
Risks- early menarche, short menstrual cycles, reduced parity, heavy bleeding
Increased risk- tall /thin women, excess alcohol and caffeine

33. Endometriosis
Most common location of endometrial implants is the ovaries, followed by deep/central pelvis and vesico-uterine pouch
60% of Stage IV disease involves intestinal tract (rectum, sigmoid, colon, appendix, small bowel)
With Stage IV disease- pain mediated by deep infiltrating endometrial lesions in muscular propria of surrounding organs
ASRM stages based on size ( <1, 1-3, >3 cm), depth of invasion (superficial vs deep), and extent and consistency of adhesions ( filmy vs dense)
Stage I (minimal) 1-5 points
Stage II (mild) 6-15 points
Stage III (moderate) points
Stage IV (severe) > 40 points

34. Endometriosis Treatment
1st line- NSAIDs and hormonal therapy
If pain is refractory, surgical intervention is warranted, with laparoscopic ablation or removal (preferred) of endometrial implants
With significant bowel/bladder involvement, laparotomy may be required
Can be found incidentally on laparoscopy/laparotomy.
Can cause acute abdominal process ie small bowel obstruction via endometrioma

35. Endometriosis
MRI- superior for detection of endometriomas- hyperintense signal of T1 weighted imaging or hypodense signal of T2 imaging
CT- endometrioma appears as cystic mass with hyderdense clot within
US- used to assess endometrioma involving ovary- hypoechoic cystic structure
CT and MRI infrequently used for diagnosis, but can be helpful in the acute setting.

36. Endometrioma on MRI
T1 hyperintesne

37. Endometrioma on US

38. Endometriosis on laparoscopy

39. Catamenial pneumothorax
Recurrent pneumothorax occurring within 72 hours of onset of menses.
SOB, CP, cough; usually RIGHT sided
Manifestation of thoracic endometriosis, likely via transdiaphragmatic lymphatic/vascular transplantation of endometrial tissue
Confirmed by presence of endometrial glands and stroma within pleura or diaphragm
Medical management alone- high recurrence rate than surgical intervention.
Current recommendations- VATS with removal/ablation of implants and pleurodesis, followed by 6 months of hormonal therapy ( OCPS, GnRH agonists)

40. Ruptured/Hemorrhagic Ovarian Cysts
Most common- functional cysts, including corpus luteal cysts/ follicular cysts, which are more prone to rupture due to increased vascularity as part of the menstrual cycle
Rupture typically occurs between days of menstrual cycle (i.e. luteal phase, after ovulation has occurred)

41. Ruptured/Hemorrhagic Ovarian Cysts
Mittelschmerz- sensation of pain and release of peritoneal fluid associated with physiologic rupture of corpus luteum, cyst during ovulation
Ruptured cyst- most commonly right sided
Usual symptoms- acute pain, vaginal bleeding, nausea/vomiting, shoulder tenderness
If associated with massive hemorrhage- signs of circulatory collapse

42. Ruptured/Hemorrhagic Ovarian Cysts
Ultrasound- thin wall, anechoic; with hemorrhage and clotting of blood- internal echoes appear with fluid and debris
With massive hemorrhage- free intraperitoneal fluid present, while cyst itself is collapsed

43. Hemorrhagic Ovarian Cysts
4 diffferent echographic findings to evaluation of cysts, making conclusive initial diagnosis difficult, so many times repetition of examination is required.

44. Ruptured/Hemorrhagic Ovarian Cysts
Hemodynamically stable- conservative management, analgesia, observation
Unstable- emergent surgical intervention, even if diagnosis is uncertain
If active/uncontrollable bleeding present- oophorectomy recommended; otherwise, conservative management with preservation of ovary is preferred
If patient is clinically stable but there is no improvement with conservative management- laparoscopic ovarian cystectomy is preferred.
For outpatient management of cysts- intervention is not warranted if asymptomatic, premenopausal, cyst < 10 cm, and simple appearing.
If postmenopausal, ok to monitor cysts < 3 cm without complex appearance.

45. Ovarian Torsion
Partial/complete twisting of adnexa around its vascular pedicle ( infundibulopelvic ligament and tubo-ovarian ligament)
Vascular and lymphatic obstruction results, leading arterial occlusion and ovarian necrosis
Right adnexa most commonly involved, possibly due to longer utero-ovarian ligament on the right vs. decreased mobility of left adnexa due to presence of sigmoid colon

46. Ovarian Torsion
Commonly associated with ovarian mass (cyst, neoplasm, etc) as a fixed point around which adnexa may twist
Previous pelvic surgery also increases risk, likely due to post surgical adhesions around which adnexa can twist
Patients with ovarian hyperstimulation syndrome (due to assisted reproductive technology) also at increased risk

47. Ovarian Torsion
Acute pelvic/abdominal pain; prolonged pain associated with high risk of necrosis
Nausea, vomiting, dysuria, urinary retention, frequency, urgency
Low grade leukocytosis/fever less common
Peritoneal signs
DDx- appendicitis, PID, TOA, ectopic, cyst, cholecystitis.

48. Ovarian Torsion Ultrasound- gold standard
Enlarged ovary (>5 cm) with edema
Absent arterial/venous flow is highly specific for torsion
Pelvic free fluid present with infarction/hemorrhage

49. Ovarian Torsion
No Doppler Flow

50. Ovarian Torsion
“Whirlpool sign”

51. Ovarian Torsion
Preferred surgical treatment- laparoscopic detorsion with salvage of adnexa
Oophorectomy warranted if ovary appears necrotic, ovarian mass present, or there is evidence of peritonitis
If ovary is salvageable, consider ovarian suspension to decrease likelihood of recurrence.

52. Ovarian Torsion

53. Ovarian Torsion

54. Ovarian Torsion in Pregnancy
Adnexal torsion is the most common complication of an adnexal mass occurring during pregnancy, typically in 1st and 2nd trimesters
If ovarian mass without torsion is noted, surgery is performed in 2nd trimester
If torsion is present, surgery is warranted regardless of gestational age
Most common ovarian tumor in pregnancy- dermoid, following by corpus luteum cyst, simple cyst.

55. Uterine Fibroids
Most common pelvic tumor in women; consist of hormonally responsive smooth muscle cells, which can lead to progression during pregnancy or with hormonal contraceptive use, and typically regress after menopause
Most common symptoms- abnormal vaginal bleeding, pelvic pain and pressure
Hydronephrosis can occur with chronic impingement of ureter

56. Uterine Fibroids
Degenerating fibroids that have outgrown/lost blood supply can present as acute abdominal pain
Ultrasound- anechoic, irregular cystic spaces within the fibroid, indicating necrosis

57. Ectopic Pregnancy
Defined as any pregnancy outside uterine cavity, most commonly in the fallopian tube (ampulla> isthmus> fimbria), abdominal cavity, ovary, cervix, or uterine cornua Typically occur between 6-10 weeks gestation, and is the leading cause of death during the 1st and 2nd trimesters of pregnancy

58. Ectopic Pregnancy
Risk factors- previous ectopic pregnancy, history of PID, previous pelvic surgery, smoking, infertility, intrauterine device use
Symptoms- pelvic pain, vaginal bleeding
Quantitative bHCG- initial test
if >1500 mIU/mL, pregnancy can be seen on transvaginal US
If > 5000 mIU/mL, pregnancy can be seen on abdominal US

59. Ectopic Pregnancy
US evaluation- 1st evaluate if pregnancy is intrauterine; at 5 weeks gestation (corresponding to bHCG between mIU/mL) a gestational sac should be visible

60. Ectopic Pregnancy
With ectopic pregnancy- gestational sac/fetal pole +/- cardiac activity seen outside the uterine cavity
Adnexal mass separate from ovary with empty uterus, free fluid in pelvis, tubal “donut” sign and “ring of fire” on Doppler ultrasound

61. Ectopic Pregnancy on US

62. Ectopic Pregnancy- “Ring of Fire”

63. Ectopic Pregnancy
If unruptured and hemodynamically stable- can consider conservative management with medical therapy i.e. Methotrexate with follow up of serial bHCG levels at day 4 and day 7 after injection, and then weekly until negative
If bHCG fails to decrease by 15% from day 4 to day 7 after MTX injection, consider additional MTX injection vs. surgery
MTX can be given as a single or multiple dose regime. MTX is a dihydrofolate reductase inhibitor, and inhibits DNA synthesis of trophoblastic cells
Contraindicated with renal or liver failure, PUD, leukopenia, thrombocytopenia, pulmonary disease, or immunocompromised.

64. Ectopic Pregnancy
If ruptured, emergent surgery is indicated, especially if hemodynamically unstable
Depending on degree of patient stability, surgical approach via laparoscopy (preferred) versus laparotomy, with salpingostomy versus salpingectomy
Salpingectomy indicated with uncontrolled bleeding, severely damaged fallopian tube, large gestational sac (> 5 cm)
If ectopic is ovarian- oophorectomy indicated. If cornual involvement- cornual resection vs hysterectomy indicated.
Salpingostomy failure rate approx 8% and requries serial bHCG levels until undetectable. Can also treat failures with MTX

65. Ectopic Pregnancy

66. Appendicitis in Pregnancy
1/ /1500 pregnancies, incidence slightly higher in the second trimester
Appendiceal rupture occurs more frequently in pregnant women, especially in the third trimester -possibly due to inconclusive symptoms/reluctance to operate on pregnant women delaying diagnosis and treatment; associated with higher risk of fetal loss (36% vs. 1.5%)
Perforation is associated with significantly higher risk of fetal loss (36% vs 1.5%)

67. Appendicitis in Pregnancy
Less likely classic presentation, especially in late pregnancy
More GI complaints
Leukocytosis is common with pregnancy
Pain typically originates at McBurney's point regardless of the stage of pregnancy; however, location of the appendix migrates a few centimeters cephalad with the enlarging uterus
In the third trimester, pain may localize to the mid or even the upper right side of the abdomen
The pain is periumbilical initially and then migrates to the right lower quadrant as the inflammatory process progresses]. Anorexia, nausea and vomiting, if present, follow the onset of pain. Fever up to 101.0ºF (38.3ºC) and leukocytosis develop later.
However, many patients have a nonclassical presentation, with symptoms such as heartburn, bowel irregularity, flatulence, malaise, or diarrhea. If the appendix is retrocecal, patients often complain of a dull ache in the right lower quadrant rather than localized tenderness. Rectal or vaginal examination in such patients is more likely to elicit pain than abdominal examination

68. Appendicitis in Pregnancy
US- wide variation in the diagnostic performance during pregnancy; gravid uterus can interfere with visualizing the appendix and performing graded compression (particularly in the third trimester)
CT imaging- when clinical findings and ultrasound examination are inconclusive and MRI is not available
Also- gestational age, maternal BMI, and the training and experience of the sonologist/radiologist
CT scan 3 mGY, much less radiation than that needed for carcinogenesis of fetus ie 30 mGy, 50 mGy for deterministic effects
MRI preferable over CT for inconclusive US ie no ionizing radiation,; not a good option if not readily available and will cause delay in diagnosis.

69. Appendectomy in Pregnancy
Open  preferred if late gestation
Laparoscopic
slight left lateral positioning if 2nd trimester and beyond
avoid cervical instrumentation
open entry techniques/ trocar placement under direct visualization
limit intra-abdominal pressure to less than 12 mmHg
incision at McBurneys point vs low vertical midline incision

70. Cholelithiasis in Pregnancy
Gallstones are more common during pregnancy- decreased gallbladder motility/increased cholesterol saturation of bile
Estrogen increases cholesterol secretion
Progesterone reduces bile acid secretion and slows gallbladder emptying, promoting the formation of stones via biliary stasis
In pregnant women with biliary colic, supportive care will lead to resolution of symptoms in most cases, but the symptoms frequently recur later in pregnancy

71. Cholelithiasis in Pregnancy
1st episode - supportive care vs. cholecystectomy (laparoscopic if in 1st/2nd trimesters)
low risk of fetal mortality and high risk of disease relapse/need for urgent surgery later in pregnancy.
Acute cholecystitis  cholecystectomy
If near term- conservative management is preferable as surgery is technically difficult, with plan for cholecystectomy 6 weeks postpartum

72. The End! Questions?