Internal Medicine: Open Access
Open Access

Commentary on Abdominal Pain: A Common Presentation with Unusual Diagnosis

Yeshaswini PS Reddy^{* *}Correspondence: Yeshaswini PS Reddy, Department of Medicine, University of Illinois College of Medicine-Peoria, Illinois, USA, Email:

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Description

Abdominal pain is a very common complaint especially in young female patients which if neglected can lead to further complications. This case report describes a young female suffering from abdominal pain for many years without an appropriate diagnosis, and was diagnosed with Irritable Bowel Syndrome. She presented to the emergency room with acute right sided abdominal pain associated with nausea and vomiting. Physical exam was positive for right lower quadrant tenderness. A computerised tomography of the abdomen and pelvis demonstrated a mobile cecum in the left abdomen without evidence of obstruction or volvulus. She subsequently underwent a diagnostic laparotomy with cecopexy and appendectomy. Intra operatively the right colon was unusually mobile. The right-sided lateral peritoneal reflection was found to be very loose with easy visibility of the right kidney, duodenum, and pancreas with simple retraction of the right colon. All of the above findings are very typical for cecal volvulus and were suspected to be the cause of her chronic abdominal symptoms. Pathology of the appendix showed findings suggestive of endometriosis and intraluminal Enterobius vermicularis. She was treated with two doses of pyrantel pamoate for the parasitic infection and had resolution of her symptoms.

This case report emphasises the importance of having a broad differential diagnosis and performing a thorough work up before diagnosing a functional syndrome. This patient may have had complications including bowel ischemia and necrosis if left untreated. Right lower abdominal pain is very typical for appendicitis which was the initial diagnosis however less likely possibilities such as volvulus, endometriosis, or parasitic infections should be considered. Diagnosing volvulus preoperatively is very difficult since it mimics appendicitis. This condition is a rare congenital anomaly with loss of fixation of the cecum and ascending colon to the peritoneum during embryogenesis. If neglected, this can lead to perforation and death.

Endometriosis is another easily missed diagnosis in females which can be overlooked since it can mimic other gastrointestinal disorders as it most commonly involves the rectum, sigmoid colon, and the appendix. This was not considered as a differential diagnosis in our patient since her symptoms had no correlation with her menstrual cycle. Lastly, parasitic infections are almost never considered as the differential diagnosis due to a low incidence in the United States when compared to the developing world; it is often seen in children due to poor hygiene. For the above reasons, we present this case to reinforce the need to be mindful of a broad differential diagnosis before attributing the presentation to a functional syndrome. A thorough evaluation should be performed to ensure accurate diagnosis, decrease adverse events, and reduce mortality. Despite all the diagnostic modalities available today, it can be difficult to diagnose certain diseases preoperatively and may need further evaluation including histopathology. Especially when there can be upto 50% of the patients with mobile cecum who present with recurrent abdominal pain that is relieved with passing gas or bowel movement it is very easy to be mistaken with irritable bowel syndromes as this may lead to ischemic bowel, necrosis, and perforation when it is neglected