Right lower quadrant pain and ovarian cancer. It is clear. Why should we make a differential diagnosis?
A 47- year- old woman was receiving chemotherapy because of a stage III ovarian cancer. She went to the Emergency Room (ER) with a low fever (37º centigrades), nausea and pain in her abdomen.
The physical examination showed tenderness in her right lower abdominal area, with normal bowel sounds. A previous abdominal CT scan three weeks before, showed the presence of abdominal masses in relation to her ovarian cancer.
She was discharged home with a diagnosis of “abdominal pain in relation to abdominal metastatic ovarian cancer”.
Two days later, the patient started again with pain and nausea and she went back to the ER. The physical examination was similar, with a stronger pain in the right lower abdominal quadrant, together with some findings suggestive of peritoneal implication.
The abdominal sonogram showed a moderate amount of ascites , appendicular inflammation and a phlebolith inside the appendix.
We show here the CT scan
Final Diagnosis: Appendicitis
Comments: usually interns and doctors in general see the situation so clear in their minds that they are reluctant to think ahead, even they feel ashamed if they write a list with a “common” disease as appendicitis in a patient with another important disease as an ovarian cancer.
The delay in the diagnosis is important in terms of hours in this clinical situation, because an infection of the appendix, without a correct treatment can be deleterious for the patient in a short period of time.
Although it is logical to think of explaining a clinical picture with a single process, sometimes this is not possible. “Going for the obvious makes sense, but it is often associated with persistent behavior attempting to diagnose the obvious, failing to look for other possibilities, and calling off the search once something is found” (Sutton´s slip) (1) .
- Croskerry, P, Cosby KS, Graber ML, Singh H. Diagnosis interpreting the shadows. CRC Press. 2017 Taylor & Francis Group, LLC
Author: Lorenzo Alonso, MD