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Cysts, Infection, Abdominal Pain, Pregnant, Kidney Stone, Gentamicin, Vitamin C, Laparotomy, Abdomen Ultrasound, Blood Tests
Question: This enquiry is for XXXXXXX She had a laparatomy on 24th of March this year and an orange sized cysts taken out. She was admitted at CWM hospital for a week and discharged. After being discharged she developed an infection which she says was due to the antibiotics she took that was given to her by the doctors. (I guess could be after care - humid and sweating temperatures 28-32degree)
The infection was treated by the doctors of CWM. Since the operation she has been having pains on the right side of her abdomen which triggered off 2 hours after the operation presumably when pain killer wore down.
The doctors thought she had appendicitis. She went to a private clinic since her husband was not satisfied of the doctor diagnosis with the end result as doctors were eyeing for a second operation. The private doctor requested for an Ultrasound scan done at Suva Private Hospital. The Radiologist explained that due to her pregnancy he was not be able to see appendix but has confirmed that there are multiple stones in her gall bladder.
When admitted in hospital a month later in late April for the infections, Doctors have said that it could be appedicities, if the pain would have increased but it is not because the pain is improving after antibiotics (GENTAMYCIN) given. The antibiotics has been changed to ampiclin.
I understand this antibiotic Gentamycin is not tested for patients with pregnancy. So XXXXXXX after getting discharged underwent vitamin c i.v. to help reduce infection. but she still has the pain (She is saying that about 60% pain is still there, she also said that when she was given this treatment she was feeling ok for about 2 hours and after that the pain started coming, sometimes the pain is mild and sometimes its throbbing ), according to Dr XXXXXXX she has said that the amount of vitamin C given to her should have been sufficient for her to recover. Dr. XXXXXXX has said for her to undergo Laparoscopy.
As for the pain, doctors at the hospital also thought foreign material swab could be left inside after operation which they have to confirm. They said it can also be Kidney stone which they had not ruled out and have asked her if she wants she can get leptoscopy or laparoscopy done as they can’t do x-ray as pregnancy is just 13 weeks.
What is your advice. Could it be when stitching back they could have clipped a bit of an organ because the baby in the stomach is pushing them which has left little space?
Given that this pain was not there prior to the operation, hence it is possible that the stones found in the gall bladder may not be what is giving the symptoms as this pain was not there until after the operation.
Since she still is having the pains would should she do next?
Abdomen Ultrasound 10/05/2011
She has single live fetus in sephallic presentation; Cervix is closed and is 3cm long; Placenta is anterior tundal. Mean Gestational Age = 14 weeks 5 days; NO fetal anormally.
Maternal Scan: has multiple calculli in the gall bladder. No evidence of cholecystitis. Bile duck are not dilated; Renals are normal in sizes with no calculli hydronephrosis.
Cannot see the appendix, however she is tender in the Rt iliac fossa region. Need to be correlated clinically. No free fluid.
Blood results: 11/05/2011
Hb 103* g/L (115-165
WCC 11.2* x10~9/L (3.9-11.1) (Neutrophil 7.8 (2.0-8.0); Lymphocyte 2.7 (1.0-4.0)
Plat 376* x10~9/L (150-400) ESR 10mm/hr
RCC 3.8* x10~12/L (3.90-5.0)
PCV 0.28* L/L (0.36-0.44)
MCV 79.0* fL (82-98)
MCH 27 pg (27-32)
MCHC 342 g/L (300-350)
RDW 15.8* fL (9-15)
Normocytic normochromic anamia. White cells and platelets show no significant morphological abnormality.
The infection was treated by the doctors of CWM. Since the operation she has been having pains on the right side of her abdomen which triggered off 2 hours after the operation presumably when pain killer wore down.
The doctors thought she had appendicitis. She went to a private clinic since her husband was not satisfied of the doctor diagnosis with the end result as doctors were eyeing for a second operation. The private doctor requested for an Ultrasound scan done at Suva Private Hospital. The Radiologist explained that due to her pregnancy he was not be able to see appendix but has confirmed that there are multiple stones in her gall bladder.
When admitted in hospital a month later in late April for the infections, Doctors have said that it could be appedicities, if the pain would have increased but it is not because the pain is improving after antibiotics (GENTAMYCIN) given. The antibiotics has been changed to ampiclin.
I understand this antibiotic Gentamycin is not tested for patients with pregnancy. So XXXXXXX after getting discharged underwent vitamin c i.v. to help reduce infection. but she still has the pain (She is saying that about 60% pain is still there, she also said that when she was given this treatment she was feeling ok for about 2 hours and after that the pain started coming, sometimes the pain is mild and sometimes its throbbing ), according to Dr XXXXXXX she has said that the amount of vitamin C given to her should have been sufficient for her to recover. Dr. XXXXXXX has said for her to undergo Laparoscopy.
As for the pain, doctors at the hospital also thought foreign material swab could be left inside after operation which they have to confirm. They said it can also be Kidney stone which they had not ruled out and have asked her if she wants she can get leptoscopy or laparoscopy done as they can’t do x-ray as pregnancy is just 13 weeks.
What is your advice. Could it be when stitching back they could have clipped a bit of an organ because the baby in the stomach is pushing them which has left little space?
Given that this pain was not there prior to the operation, hence it is possible that the stones found in the gall bladder may not be what is giving the symptoms as this pain was not there until after the operation.
Since she still is having the pains would should she do next?
Abdomen Ultrasound 10/05/2011
She has single live fetus in sephallic presentation; Cervix is closed and is 3cm long; Placenta is anterior tundal. Mean Gestational Age = 14 weeks 5 days; NO fetal anormally.
Maternal Scan: has multiple calculli in the gall bladder. No evidence of cholecystitis. Bile duck are not dilated; Renals are normal in sizes with no calculli hydronephrosis.
Cannot see the appendix, however she is tender in the Rt iliac fossa region. Need to be correlated clinically. No free fluid.
Blood results: 11/05/2011
Hb 103* g/L (115-165
WCC 11.2* x10~9/L (3.9-11.1) (Neutrophil 7.8 (2.0-8.0); Lymphocyte 2.7 (1.0-4.0)
Plat 376* x10~9/L (150-400) ESR 10mm/hr
RCC 3.8* x10~12/L (3.90-5.0)
PCV 0.28* L/L (0.36-0.44)
MCV 79.0* fL (82-98)
MCH 27 pg (27-32)
MCHC 342 g/L (300-350)
RDW 15.8* fL (9-15)
Normocytic normochromic anamia. White cells and platelets show no significant morphological abnormality.
Medical History:
24 year old - first pregnancy 17 weeks now. At 8 weeks of pregnancy, removed an orange sized cyst. 2 hours post operation, pain set in and remains since - mild- sometimes throbbing. No pain prior to operation, although now found in Maternal scan of multiple calculli in the gall bladder. no signs of cholecystitis. Cannot see appendix, but is tender in the Rt iliac fossa region in the scan 2 weeks ago. No free fluid
24 year old - first pregnancy 17 weeks now. At 8 weeks of pregnancy, removed an orange sized cyst. 2 hours post operation, pain set in and remains since - mild- sometimes throbbing. No pain prior to operation, although now found in Maternal scan of multiple calculli in the gall bladder. no signs of cholecystitis. Cannot see appendix, but is tender in the Rt iliac fossa region in the scan 2 weeks ago. No free fluid
Dear XXXXXXX !
Thanks for the mail.
It is difficult to judge the exact cause of the right side abdominal pain without following the case from the start of it.
Modern surgical techniques are protocol based and it is less possibility of clipping an organ during the surgery.
Right side abdominal pain can be from all the causes that were mentioned by the doctors there. When the investigations and clinical examination is not helping to arrive at a diagnosis, I would rely 'On Operation Table Diagnosis' done during operation. If I were her surgeon and If the pain is significant and disturbing her day to day life I would go ahead and do a laparoscopic cholecystectomy and appendicectomy as she is in the second trimester which is the safest peiod of pregnancy for any surgical intervention.
Surgery at a later date may be determental to the baby.
Regards
Thanks for the mail.
It is difficult to judge the exact cause of the right side abdominal pain without following the case from the start of it.
Modern surgical techniques are protocol based and it is less possibility of clipping an organ during the surgery.
Right side abdominal pain can be from all the causes that were mentioned by the doctors there. When the investigations and clinical examination is not helping to arrive at a diagnosis, I would rely 'On Operation Table Diagnosis' done during operation. If I were her surgeon and If the pain is significant and disturbing her day to day life I would go ahead and do a laparoscopic cholecystectomy and appendicectomy as she is in the second trimester which is the safest peiod of pregnancy for any surgical intervention.
Surgery at a later date may be determental to the baby.
Regards
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dr Ji,
Thank you for the reassurance. Can you please see below and give your further comments on items 1,2 and 3.
Thank you
Santa XXXXXXX
----- Original Message -----
From: XXXXXXX
To: 'XXXXXXX'
Sent: Friday, May 27, 2011 10:45 AM
Subject: RE: XXXXXXX results and next steps to be taken
1) What was operated for where the cysts were?
A cyst was removed from lower right. This is where the pains eventuated from. The size of the cyst was 12.7x11.8x7.3 cm
2) Was she in pain and since when as to why cyst was discovered?
Yes she was in pain, the cyst was discovered when she went for her normal checkup for pregnancy, Was discovered and 24th of march and removed the same day as doctors said that her ovary was getting tortured. Till today I have not been told Whether the whole ovary or only the cyst was removed.
3) Or was it found due to pregnancy and started the symptoms and what was the symptoms for how long into pregnancy. I am not sure about this
This will give some specifics for your questions to be understood and expressed for most probable etiology.
Please contact my email if more questions need to be clarified
EXTRA QUESTION FROM PATIENT:
[1] XXXXXXX wants to know that after getting her cyst removed and now getting the relevant things done what is the chance of having a normal delivery?
[2] Will she be getting a Caesar or something similar to that?
I also had a chat with the XXXXXXX Dr (Dr fong) at CWM who has ruled out appendicitis as it has been 4 weeks from when she was admitted for possible appendicitis. Dr XXXXXXX has said that if it was appendicitis it would have inflamed and burst up by now
[3] Please ask the Dr XXXXXXX Patta to confirm if we can be rest assured that it is not appendicitis.
I will answer that -Specialist cannot reassure you this because only a clinical examination and level of tenderness etc, will determine that which needs to be correlated by specialist attending to her. I am sure the specialist will agree.
Thank you for the reassurance. Can you please see below and give your further comments on items 1,2 and 3.
Thank you
Santa XXXXXXX
----- Original Message -----
From: XXXXXXX
To: 'XXXXXXX'
Sent: Friday, May 27, 2011 10:45 AM
Subject: RE: XXXXXXX results and next steps to be taken
1) What was operated for where the cysts were?
A cyst was removed from lower right. This is where the pains eventuated from. The size of the cyst was 12.7x11.8x7.3 cm
2) Was she in pain and since when as to why cyst was discovered?
Yes she was in pain, the cyst was discovered when she went for her normal checkup for pregnancy, Was discovered and 24th of march and removed the same day as doctors said that her ovary was getting tortured. Till today I have not been told Whether the whole ovary or only the cyst was removed.
3) Or was it found due to pregnancy and started the symptoms and what was the symptoms for how long into pregnancy. I am not sure about this
This will give some specifics for your questions to be understood and expressed for most probable etiology.
Please contact my email if more questions need to be clarified
EXTRA QUESTION FROM PATIENT:
[1] XXXXXXX wants to know that after getting her cyst removed and now getting the relevant things done what is the chance of having a normal delivery?
[2] Will she be getting a Caesar or something similar to that?
I also had a chat with the XXXXXXX Dr (Dr fong) at CWM who has ruled out appendicitis as it has been 4 weeks from when she was admitted for possible appendicitis. Dr XXXXXXX has said that if it was appendicitis it would have inflamed and burst up by now
[3] Please ask the Dr XXXXXXX Patta to confirm if we can be rest assured that it is not appendicitis.
I will answer that -Specialist cannot reassure you this because only a clinical examination and level of tenderness etc, will determine that which needs to be correlated by specialist attending to her. I am sure the specialist will agree.
Dear XXXXXXX
Thanks again,
Now I understand that the operation done earlier was probably for a twisted ovarian cyst. Its possible that the entire ovary with the cyst was removed (that is what is necessary).
In all likelihood, she will have a normal delivery in spite of her cyst surgery. She will also not require a caeserean unless other complication occur.
Now regarding the issue of appendicits - according to me, appendicitis can't be ruled out completely. It is very difficult for a clinician to comment or speculate based on patient complaints. A diagnosis can be confirmed after analyzing previous records, blood reports and scans. In this case, per operative findings (during surgery) would be crucial in determining the cause.
Wish her healthy pregnancy and normal delivery!!
Regards
Thanks again,
Now I understand that the operation done earlier was probably for a twisted ovarian cyst. Its possible that the entire ovary with the cyst was removed (that is what is necessary).
In all likelihood, she will have a normal delivery in spite of her cyst surgery. She will also not require a caeserean unless other complication occur.
Now regarding the issue of appendicits - according to me, appendicitis can't be ruled out completely. It is very difficult for a clinician to comment or speculate based on patient complaints. A diagnosis can be confirmed after analyzing previous records, blood reports and scans. In this case, per operative findings (during surgery) would be crucial in determining the cause.
Wish her healthy pregnancy and normal delivery!!
Regards
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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