Problem Based Learning

"My stomach really hurts down there"

Ebony Sloan

Learning Objectives

At the completion of this module, the participant will be able to:

 Demonstrate understanding of differential diagnosis of lower abdominal pain

 Describe how to diagnose PID

 Formulate plan to treat a patient with PID

History

Ebony is a patient you have seen a few times in your continuity clinic. She is 16 years old. She has reported being sexually active in the past, but she has never been willing to try a hormonal method of birth control. She called this morning saying "My stomach really hurts down there." ______

1. What is the differential diagnosis you are thinking about?

GI Acute appendicitis Acute cholecystitis Inflammatory bowel disease Constipation Gastroenteritis

Genital tract PID Ectopic pregnancy, Septic or threatened abortion Ovarian cyst with or without rupture or torsion Endometriosis Dysmenorrhea Mittelschmerz

Urinary system Acute pyelonephritis Cystitis, Urethritis Renal stone

2. What other questions do you want to ask her?

Type of pain: onset, duration, quality, location Systemic symptoms: Fever, chills GI symptoms: nausea, vomiting chills GU symptoms: Vaginal discharge, dysuria, dyspareunia Sexual history: number of partners, number new partners in 2 months, symptoms in partners Menstrual history: LMP, recent patterns, onset of pain related to LMP, change in flow, dysmenorrhea Contraception history: barrier methods, IUD, OCPs Drug history: particularly illicit drugs, especially crack Vaginal douching Previous STDs or PID

History of Present Illness

The pain started 3 days ago. She describes it as across the lower abdomen, on both sides. Sometimes it gets worse, but it is not really crampy. It increases with walking around, and she and her boyfriend had to stop having sex last night because of the pain. It has gradually increased over the last 3 days, and now she doesn't want to move. She also reports decreased appetite. She denies fever, chills, nausea, vomiting, diarrhea, vaginal discharge, or pain with urination.

Past Medical History

Previously had Chlamydia (about 1 year ago) that was treated at the county health clinic.

Menstrual History

Her first menses was at age 12, and has been regular for the last 2 years. They last about 5 days and she has minimal cramping. Her last period finished a little over a week ago. It was heavier than normal.

Social History

Home - Ebony lives with her parents and younger siblings, and reports that it is sometimes hard to get along with her mother. Education - She has a B average in school, and wants to be a lawyer. Activities - She has many friends, and is likes to hang out at the mall. Drugs - She tried smoking cigarettes once, but didn’t like it, and admits to drinking alcohol but has only been “drunk” a few times. She denies other drug use. Sex - She reports 5 lifetime male partners, and no female partners. She first had sex at age 14, and denies abuse. She has been going out with her current boyfriend for about one month, and she doesn't think he has any symptoms. She has never used OCPs, and sometimes uses condoms. Suicide - She denies being sad or depressed

______

1. What are her risk factors for PID?

*Multiple partners:one partner = 4.6:1 *Early age of intercourse increases risk *Adolescents:women age 25-29 = 3:1 cervical ectopy, lack of local immunity, less use of barrier methods, more new partners *Non-white:white = 2.5:1 *No OCPs:OCPs = 2:1 *Substance abuse associated with multiple partners and failure to use condoms Vaginal douching:no douching = 2:1 Older IUDs increased risk of PID within 2 months of insertion. With PID:without PID = 2.3:1 for previous PID

2. What do you look for on PE/labs?

Vital signs Abdominal exam Pelvic exam Wet mount ß-hcg Cervical cultures CBC, ESR?

3. What are the sequelae of PID?

Recurrence in 12 - 33% TOA in as many as 1/3 of hospitalized patients Fitz-Hugh Curtis syndrome Infertility: 1st episode - 13-21% 2nd episode - 35% 3rd episode - 55-75% Ectopic pregnancy - 6-10 times greater risk than normal Chronic abdominal pain, exacerbated dysmenorrhea, dysparunia in 18% (adhesions around ovaries?)

4. What organisms are involved?

About 50% have CT or GC from endocervix 2/3 have both anaerobes and aerobes on laparotomy specimens Mixed anerobes (Bacteroides, Peptostreptococcus) Facultative bacteria (Bardenerella vaginalis, Streptocuccus, E. coli, H. infuenzae) Genital tract organisms (Mycoplasma hominis, Ureaplasma urealyticum)

Physical Examination

General: Quiet, young African-American woman in a gown sitting on the exam table

VS: T = 37.9 BP = 112/72, ht = 64 in. (50%), wt = 115 lbs. (40%) Abdomen: +BS, soft, diffusely tender across lower abdomen

GU External genital exam: no lesions Vagina: no discharge or lesion Cervix: small amount of yellow discharge, cervix bleeds when touched with Q-tip Adnexa: tenderness bilaterally, no masses Uterus: pt screams, and moves up the table when you push cervix to the side Urethra: no tenderness

Labs: ß-hcg - neg vaginal pH - 4.3 Wet mount - many WBC, no trichomonas or clue cells ______

1. How do you interpret this information?

Diagnostic Criteria for PID without signs of competing diagnoses: Minimum Diagnostic Criteria Uterine/adnexal tenderness (bilateral or unilateral) OR Cervical motion tenderness Additional Diagnostic Criteria Oral Temp > 38.3 Abnormal cervical or vaginal discharge WBC on wet mount Elevated ESR or CRP Positive CT or GC Definitive Diagnostic Criteria Transvaginal ultrasound or MRI showing thickened, fluid filled tubes with or without free pelvic fluid or tubo-ovarian abscess Histopathologic evidence of endometritis on endometrial biopsy Tubo-ovarian abscess on ultrasound Laparoscopic abnormalities consistent with PID

Management and Counseling

You explain the diagnosis and cause to Ebony. You recommend that she come into the hospital to treat the infection with the strongest medicines that you have.

She is very upset and asks you, "I'll come into the hospital, but I don't want my parents to find out."

______

1. How do you respond? "I will keep this information confidential" "I will not lie to your parents" "If your family asks, I can only say, 'This is a problem that Ebony can consent for her own treatment, and I cannot talk to you about this without her consent'" "The hospital will not admit you without your parents' permission" "In a hospital, there are many people that will be working to help you, and they may accidentally let it slip" "You may get a notice from your insurance that contains the diagnosis (labs, hospitalization, etc)"

2. What are admission criteria for PID? Does not respond clinically to outpatient (oral) therapy Uncertain diagnosis/can’t rule out surgical abdomen Adnexal mass/TOA Severely ill patient or peritonitis Pregnancy Some authors suggest - suspicion of inability of the adolescent to follow or tolerate outpatient therapy

3. What are treatment options? Cefoxitin 2 g IV Q 6 hrs or Cefotetan 2 g IV Q 12 hrs + Doxycycline 100 mg IV or PO Q12 hrs as inpatient discharge on Doxycycline 100 mg PO Q 12 hrs for 14 day total Clindamycin 900 mg IV Q 8 hrs plus Gentamycin as inpatient discharge on Doxycycline 100 mg PO Q 12 hrs for 14 day total or Clindamycin 450 mg PO Q 6 hrs for 14 day total Ofloxacin 400mg IV Q12hrs or Levofloxacin 500mg IV QD + Doxycycline 100 mg PO/IV Q 12 hrs +/- Metronidazole 500 mg Q8 or Ampicillin/Sulbactam 3 g IV Q 6 hrs discharge on Ofloxacin or Levofloxacin PO for 14 day total

Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO Q12 hrs for 14 days +/- Metronidazol 500mg PO Q 12 hrs Ofloxacin 400 mg PO Q12 hrs or Levofloxacin 500 mg PO Q day for 14 days

+/- Metronidazole 500 Q12 hrs for 14 days

Epilogue

Ebony's hospitalization progresses without incident. She is started on Cefoxitin, 2g IV every 6 hours and doxycyline 100 mg orally every 12 hours. Her mother accepts the explanation of "an infection" visits mostly in the evening, and doesn't ask many questions. Ebony's boyfriend comes in one afternoon and gets a prescription for one capsule of Ciprofloxacin (500 mg), and four tablets of Azithromycin (250mg). Two days after admission, you repeat the bimanual exam, and there is markedly decreased CMT and no adnexal tenderness or mass. Ebony is discharged on Doxycycline tabs (100mg) twice a day for 12 more days, and condoms.

Ebony comes in the next week for follow-up. Things are going OK with her mother, and she has no new problems. Her gonorrhea culture comes back positive, and the Chlamydia PCR comes back negative. At the end of the visit, Ebony says, "Thank you so much for helping me, I was wondering... can you tell me more about birth control pills?"