Endometriosis with salpingitis simulating acute appendicitis

Abstract

(5 MHz, 6 MHz convex and linear probes; Wipro GE LOGIQ P3) with a partially distended urinary bladder revealed bilateral complex adnexal masses with internal echoes ( Figure 1A, B) abutting the uterus. The uterus, however, was found to be normal. The ovaries could not be demonstrated separately. Free fluid was present in RIF as well as pouch of Douglas. Using graded compression, a blind ending, tubular, non-compressible and non-peristaltic structure (diameter: 7 mm) was found extending from the RIF towards the midline (Figure 2). There was probe tenderness over this tubular structure. Although, the images of the tubular structure as mentioned above were not typical for classical appendicitis, based on the clinical profile and ultrasonographic findings, possibility of atypical appendicitis in association with pelvic endometriosis was raised. The attending surgical specialist was informed about pros and cons of the ultrasonographic findings who decided in favour of surgery. At surgery, the appendix was found to be normal. Appendectomy was carried out. The incision line was extended to look for pelvic pathologies. There were bilateral endometriotic ovarian cysts (chocolate cysts) with the right ovarian cyst having been ruptured with spillage of chocolate coloured fluid contents in the pelvis and RIF. Both ovarian cysts were plastered with the uterus with extensive adhesions in the pelvis and nearby areas (grade IV endometriosis). What was thought to be an atypical appendicitis on USG was actually an inflamed and kinked right fallopian tube extending from the right iliac fossa reaching almost up to the midline with the ampullary end directed medially. There were multiple areas of endometrial implants on the fallopian tube. Opinion of gynaecologist was sought during the surgery who advised medical treatment for endometriosis. The patient has been put on tab danazol 100 mg BD and has shown good response on follow up after two months. DISCUSSIONAcute appendicitis remains the most common surgical emergency with a life-time occurrence of 7%. Despite being a common problem and technological advancement in the recent past, acute appendicitis may still pose a diagnostic dilemma even to the best of clinicians. Laboratory investigations, though useful, are often non-specific. There are a sizeable number of conditions which can mimic appendicitis, some of them are urolithiasis, pelvic inflammatory disease, pyelonephritis, haemorrhagic ovarian cyst, ovarian torsion,