An Abdominal Emergency
In 1997 Ms W, a 35-year-old with type 2 diabetes (controlled by diet and exercise) was working as a nurse on the pediatric ward. She came to the urgent care clinic at the Family Practice Center with symptoms of mild low back pain and right-sided lower abdominal pain which were associated with dysuria and frequency of urination during the previous 2 months. She had suffered an episode of low back pain 2 years earlier. Her urine showed a mildly positive leukocyte esterase test and a trace of protein, and she was given a course of trimethoprim.
Ten days later she returned reporting that the abdominal pain had become much worse, particularly when sitting and lying down, and it kept her awake at night. She complained of a feeling of fullness in the right lower quadrant of the abdomen. There were no changes in her bowel habit, and she had no fever, nausea, or anorexia. She was taking maximum doses of ibuprofen and acetaminophen for the pain. A repeat urinalysis was normal. She had previously had a hysterectomy and appendectomy, as well as polycystic ovaries, but the results of a pelvic examination were normal. Examination of the abdomen revealed normal bowel sounds and some tenderness in the right lower quadrant, close to the superior iliac spine. Because of her history of persistent back pain and a lack of explanation for her abdominal symptoms, x-rays of the lumbosacral spine and pelvis were ordered.
When she was seen again 2 days later, the abdominal pain had become much more severe. It was sharp, intermittent, not colicky, and traveled down into the groin and right anterior thigh. There was considerably less pain when she was standing. She had normal bowel sounds but was again acutely sensitive to palpation in the lower abdomen just above the anterior superior iliac crest. Assessment for acute abdominal pain included an electrolyte panel and complete blood count, which were normal except for a white blood count of 11,200. The lumbar and pelvic radiologic studies showed mild degeneration of the hip joints and some spurring of the inferior aspect of both sacroiliac joints.
With a working diagnosis of lower abdominal abscess, she was referred to the emergency department to be seen by the family medicine inpatient team. A computed tomography scan of the abdomen and pelvis was normal, showing only a small ovarian cyst on the left ovary. However, a repeat white blood count (several hours later) was 13,100. A surgical consultation was requested, but the surgeon found no evidence of an acute abdominal process, giving his opinion that this was a musculoskeletal problem.
At the suggestion of one of the family medicine faculty a more detailed examination of the sacroiliac joints was performed, and the resident found significant point tenderness over the right sacroiliac joint. Deep palpation of this joint area also produced pain radiating to the right inguinal region. It was felt that the acute abdominal problem might be caused by referred pain from the sacroiliac joint. The patient received an injection of 60 mg ketorolac tromethamine, which produced considerable relief, and she was sent home. However, there was no clear explanation for the 2 occasions of elevated white blood cell count.
At follow-up 10 days later the abdominal pain had subsided, but she was complaining of much more pain in the right lower back with referral down the front of her thighs. There was still tenderness over the right sacroiliac joint, and she was sent to a physical therapist for evaluation and treatment. During her first visit to the physical therapist, in addition to the low back symptoms she again reported increasing right lower abdominal pain that was worse when sitting, better when standing. Careful examination revealed an extremely tender 3 cm long, partly mobile, fibro-fatty nodule along the mid-region of the right iliac crest, approximately 4 inches lateral to the spinous process of the lumbar vertebra. Repeated firm, direct pressure on this nodule made the patient cry and reproduced the right lower abdominal symptoms.
Following injection with multiple puncture technique, lidocaine hydrochloride 3 cc and methyprednisolone acetate 40 mg, the patient experienced immediate pain relief with no more abdominal symptoms and no difficulty in sitting or lying down. Since that time (2 years ago), there has been no recurrence of these symptoms. Although the cause of the abdominal pain might have been a polycystic ovary, the workup did not support this conclusion and revealed no other obvious cause for the severe symptoms. Injecting a painful nodular swelling in the lower back that fitted the characteristics of previously described fibro-fatty nodules provided immediate relief of the pain, suggesting a possible association with the anterior abdominal symptoms.