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Case 155


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Female patient, 44 years old, was admitted to the ER with progressively worsening pain in the lower abdomen for the past eight days associated with nausea, vomiting and prostration. Denies fever. Bowel and urinary habits preserved. Denies vaginal discharge, as well as dyspareunia, abnormal vaginal bleeding or menstrual delay. Was diagnosed with urinary tract infection six days ago and used ciprofloxacin for three days, without improvement of symptoms. Denies comorbidities. On examination, hemodynamically stable, afebrile, moderate hypogastric pain and negative Blumberg sign. No relevant findings on gynecological exam. On the rectal exam, the patient complained of pain. Computed tomography (CT) of the abdomen and pelvis was performed.

What is the patient’s most probable diagnosis?

a) Ectopic pregnancy


b) Perforated pelvic appendicitis


c) Pelvic inflammatory disease (PID)


d) Complicated cystitis


Image Analysis 

Image 1: Computed tomography of the pelvis after intravenous injection of contrast medium, having been prior ingestion of the same product: air collection (in red) demonstrating parietal uptake of contrast medium and conditioning displacement of adjacent bowel loops.


- Pelvic appendicitis is the inflammation of the appendix located in the pelvis.

- The diagnosis of pelvic appendicitis is usually delayed due to the absence of the characteristic signs of classical appendicitis.

- On physical examination, only deep hypogastric pressure and/or pelvic region triggers pain other than the digital rectal exam.

- Imaging methods may have important role in the diagnosis.

- It is essential to perform a digital rectal exam in inconclusive abdominal cases, since it may be enough to confirm a diagnosis.

- Delayed diagnosis is common and may result in serious complications such as perforation with purulent peritonitis.


- Appendicitis Curr Probl Surg 2005;42:694-742

- Armstrong, E. Geo; Pelvic Appendicit, British Medical Journal; 1906, Jan 13 (1) 70-71

- Cope Z. Diagnóstico precoce do Abdome Agudo, Manuel Marie (Ed) Barcelona 3rd edition.

- Hooton, T. M. Acute complicated cystitis and pyelonephritis. UpToDate, 2014 [viewed in July 2014]. Available at:

- Livengood, C.H., Chacko, M.R. Clinical features and diagnosis of pelvic inflammatory disease. UpToDate, 2014 [viewed in June 2014]. Available at:

- Pryslowky J B, Pugh C M, Nagle A P – Appendicitis Curr Probl Surg Surg 2005;42:694-742

- Tulandi, T. Clinical manifestations, diagnosis, and management of ectopic pregnancy. UpToDate, 2014 [Viewed in June 2014]. Available in:

- D’Ipolito G, Caldana RG – Gastrointestinal. Colégio Brasileiro de Radiologia. Rio de Janeiro. Ed. Elsevier, 2011.


Luanna da Silva Monteiro, 6th year medical student at UFMG School of Medicine

E-mail: luannasmonteiro[at]


Prof Wilson Luiz Abrantes, general surgeon, former head of the surgery department in the Hospital de Pronto Socorro João XXIII and resigned professor at the UFMG
 School of Medicine

E-mail: wlabrantes[at]


Prof José Nelson Mendes Vieira, radiologist, professor at the UFMG School of Medicine

E-mail: zenelson.vieira[at]



Ana Luiza Tavares, Amanda Oliveira, Ana Júlia Bicalho

Translated by

Barbara de Queiroz e Bragaglia, 5th year medical student at UFMG School of Medicine

E-mail: barbara.bragaglia[at]


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