A Tale of Two Bleeders

The following are two cases of vaginal bleeding seen in the a community Emergency Department during the same shift.

CASE 1:

HPI: 30 year old G3P1 female at 5 weeks pregnancy by LMP who presents to the ED with vaginal spotting. She states it started this morning while urinating. She reports about “a spoonful” of dark red blood with no clots. Associated symptoms include transient, lower abdominal cramping. Her pregnancy has had no complications so far, and she just established pre-natal care. Her second pregnancy was complicated by preterm delivery, for which she underwent C-section.

PE: Hemodynamically stable. No abdominal tenderness, guarding, rebound, or distention. On speculum exam, there is a mild amount of dark red blood and clot in the vaginal vault. No fetal tissue. The cervical os is closed. No CMT. No uterine or adnexal tenderness.

Bedside TVUS: No IUP

What now?

In any case of vaginal bleeding, the first step is determining if the patient is pregnant or not! In this case, we know our patient is pregnant. At this point, we develop our differential:

  1. Ectopic Pregnancy

  2. Abortion

  3. Gestational trophoblastic disease

  4. Implantation bleeding

Unlike our Miranda Rights, your patient is guilty of ectopic pregnancy until proven innocent! This is one of the “can’t-miss” diagnoses that we should all feel comfortable working up and managing.

Ectopic Pregnancy:

  • This occurs when there is conception outside of the uterine cavity. Risk factors include a history of STIs (especially PID), assisted reproductive techniques, history of pelvic surgery, advanced maternal age, previous ectopic pregnancy, and cigarette smoking.

  • The vast majority of ectopics take place in the fallopian tubes (ampullary portion), with about 1% taking place in the abdominal cavity, and <1% are cervical.

  • Most patient’s report a history of missed menses, although up to 15% of patients will report normal menses.

  • Abdominal pain is present in up to 90% of patients with ectopic pregnancies (secondary to tubal distention or rupture), although the absence of pain does not rule out ectopic pregnancy!

  • The physical examination in ectopic pregnancy is variable. In cases of ruptured ectopic pregnancy, the patients may be peritoneal with adnexal tenderness and possibly present in shock. Most patients, however, present with stable vital signs. An adnexal mass or tenderness could be an ectopic, although can also be a corpus luteum cyst in the setting of normal pregnancy and/or recent ovulation. Blood may be appreciated in the vaginal vault, although pelvic examination may be normal as well.

  • Definitive diagnosis of ectopic pregnancy is by ultrasound or direct visualization during laparoscopy or surgery.

  • But what about the beta-HCG level? Although absolute levels and “doubling times” are typically longer in ectopic pregnancy, it turns out that no level can reliably distinguish between a normal and pathological pregnancy.

  • The literature describes a discriminatory zone, or beta-HCG level at which you would expect to see an IUP at 1,500 mIU/mL for transvaginal scanning and 6,000 mIU/mL for transabdominal scanning. That being said, if ectopic is suspected, ultrasound should still be performed even with low beta-HCG levels.

  • The goal of ultrasound is to locate a viable IUP and exclude ectopic pregnancy. Visualizing an IUP is reassuring, although does not definitively exclude ectopic pregnancy if the patient is at high risk for a heterotopic pregnancy. Heterotopic pregnancy (both IUP and ectopic) has increased in the general population, largely in the setting of assisted reproduction technology (currently about 1:3,000 pregnancies).

  • An empty uterus with an embryo visualized outside the uterus is diagnostic, however this is only seen in up to 10% of transabdominal scans, and up to 25% of transvaginal scans. A pelvic mass (especially adnexal) in the setting of free fluid (evaluated in the cul de sac, posterior to the uterus) is highly suggestive of ectopic pregnancy.

  • If an ultrasound is indeterminate and the patient is hemodynamically stable, the patient should have close OB/GYN follow up in two days for a repeat beta-HCG level and be given strict return precautions. However, if the patient’s beta-HCG was above the discriminatory zone, it is advisable to seek consultation in the ED prior to disposition.

  • For ruptured ectopic pregnancies, surgical treatment is the preferred treatment modality.

  • For unruptured ectopic pregnancies, in the absence of contraindications, patients who are hemodynamically stable with minimal symptoms and who have appropriate OB follow up, medical treatment with methotrexate can be considered. This is typically given as a single IM dose, although the success rate of a multiple dose regimen was shown to be higher (92.7% vs 88.1%, p<0.05).

  • Treatment failure overall occurs in about 1/3 of cases. There is about a 5% chance of ectopic rupture and patients should avoid sexual intercourse for 2-3 weeks given the risk for this.

  • Abdominal pain 3-7 days after treatment with methotrexate is a common side effect, often attributed to tubal abortion/distention, although is difficult to differentiate from treatment failure and ectopic rupture. It is suggested that these patients undergo repeat laboratory testing (CBC) and pelvic ultrasound.

 Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

Figure 1: Ectopic pregnancy within the left adnexae. Source: Radiopaedia.org

 Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

Figure 2: Fluid appreciated in the cul-de-sac posterior to the uterus. Source: Radiopaedia.org

CASE 2:

History: 36 year old female G3P2 s/p D&C for a missed abortion at 7 weeks who presents to the ED with three days of worsening vaginal bleeding. Today, she reports “a large amount” of dark, red blood with clots. She reports using a pad every 10-15 minutes. Associated symptoms include intermittent, lower abdominal cramping and fatigue. No other associated symptoms. No pregnancy complications in the past.

Pertinent PE: No abdominal tenderness, guarding, rebound, or distention. On speculum examination, there is a moderate amount of blood in the vaginal vault with clots. No fetal tissue. The cervical os is closed. No CMT. No adnexal or uterine tenderness.

Bedside TVUS: No IUP. Heterogenous material appreciated within the uterine cavity.

What now?

This is a case of a patient with retained products of conception (RPOC) following an abortion.

  • Patient’s will often present with vaginal bleeding and pelvic pain, which are expected symptoms typically associated with low morbidity.

  • In patients with heavy vaginal bleeding, prolonged bleeding greater than three weeks, fever, uterine tenderness, and/or pain not controlled by over the counter medications, further evaluation is indicated to rule out other potential etiologies (or rule in RPOC).

  • Ultrasound is the best imaging modality to assess for RPOC

  • In patients with RPOC and bleeding greater than three weeks, hemodynamic instability, or sepsis, surgical treatment is preferred.

  • Patients can otherwise opt for expectant management or medical management, which typically consists of a dose of misoprostol (intravaginally or oral), especially given its low cost, low side effect profile, and easy availability. Notably, after consultation with the patient’s OB/GYN, our patient went home on methergine (an ergot alkaloid and uterotonic medication).

And for both cases, don’t forget the rhogam for your Rh negative patients! The dose is generally 300 micrograms given IM.

Faculty Reviewer: Dr. Kristy McAteer

REFERENCES:

  1. Carusi, Daniella et al. Retained Products of Conception. UptoDate. <www.uptodate.com>. 2018.

  2. Ibrahim, Dalia, Gaillard, Frank, et al. Ectopic Pregnancy. Radiopaedia. <https://radiopaedia.org/articles/ectopic-pregnancy>. 2018.

  3. Tintinalli, et. al. Ectopic Pregnancies and Emergencies in the First 20 Weeks of Pregnancy. Emergency Medicine. 8th Edition. 2016. 628-633.HHHf

FURTHER READING:

  1. 1st Trimester Pregnancy Ultrasound Podcast Part I: http://www.ultrasoundpodcast.com/2014/10/pregnancy-ultrasound-part-1-foamed-back-back-basics-cabo-update/

  2. 1st Trimester Pregnancy  Ultrasound Podcast Part II: http://www.ultrasoundpodcast.com/2014/10/1st-trimester-pregnancy-ultrasound-part-2-ectopic-topics-foamed/

  3. EM in 5: First Trimester Bleeding https://emin5.com/2015/11/09/vaginal-bleeding-in-1st-tm-pregnancy/

  4. EM Updates: Ruling out Ectopic Pregnancy http://emupdates.com/2013/06/03/rule-out-ectopic-in-the-emergency-department/

Procedure Video: Nail Bed Laceration Repair

Do you want to hide when you realize the next patient to be seen has a complex nail bed laceration? Injured fingertips might get triaged to fast track, but nail bed repairs can be time consuming and a little daunting.

In this brief video, resident Kelly Wong and attending Nick Musisca demonstrate and discuss the appropriate management of nail bed lacerations. They review the medical management, suture technique and post-ED care, including things Dr. Wong would do differently the next time she tackles a similar repair — all in under five minutes!

Nail bed laceration repair with Dr. Kelly Wong and Dr. Nick Musisca

Intussusception Deception: An Atypical Presentation

THE CASE

A previously healthy 10 year-old male presents with one day of RLQ pain and vomiting.  He awoke earlier that morning with mild to moderate pain, ate oatmeal for breakfast, and then vomited twice. About one hour later, he was sitting at his desk at school when he suddenly developed more severe abdominal pain. He initially presented to his pediatrician’s office, and was subsequently referred to Hasbro Children’s Hospital Emergency Department. No known sick contacts and no recent travel outside Rhode Island. No prior surgeries. He denies fever, chills, respiratory symptoms, melena or hematochezia, diarrhea, or urinary symptoms.

On exam, BP 115/71, HR 80, Temp 98.5F, RR 20, SpO2 99%. He is ill-appearing and acutely distressed. He has RLQ tenderness to palpation and involuntary guarding. He has normal testicular lie without tenderness, edema or erythema.  

DIAGNOSTIC STUDIES

Lab studies notable for WBC 7.9, blood glucose 114.

Abdominal/appendiceal ultrasound was ordered and showed an enteroenteric intussusception in the RLQ with adjacent inflammation and free fluid concerning for possible focal perforation (Figure 1).

 Figure 1. “Crescent in a donut” sign. Transverse view of intestinal intussusception. The hyperechoic crescent is formed by mesentery that has been dragged into the intussusception.

Figure 1. “Crescent in a donut” sign. Transverse view of intestinal intussusception. The hyperechoic crescent is formed by mesentery that has been dragged into the intussusception.

DISCUSSION

Intussusception occurs when a part of the bowel invaginates into itself, causing venous and lymphatic congestion. Untreated, intussusception may lead to ischemia and perforation.

Classic Presentation

Intussusception most commonly occurs in infants and toddlers ages 6 to 36 months-old, and approximately 80 percent of cases occur in children younger than 2 years-old [1]. Classically, parents report 15-20 minute episodes, during which their child seems acutely distressed, characterized by vomiting, inconsolable crying, and curling the legs close to the abdomen in apparent pain. They may also describe a “normal period” between episodes or offer a history that includes grossly bloody stools.

75 percent of cases of intussusception in young children have no clear trigger. Some evidence suggests that viral illness plays a role, particularly enteric adenovirus, which is thought to stimulate GI tract lymphatic tissue, in turn causing Peyer’s patches in the terminal ileum to hypertrophy and act as lead points for intussusception [2].

Atypical Presentation

Approximately 10 percent of intussusceptions occur in children older than 5 years [3]. Unlike their younger counterparts, these patients tend to present atypically, with pathologic lead points that triggered the event [4]. The patient described above illustrates this well. At 10 years-old, he presented with peritonitis after his intussusception caused focal perforation, and had no prior history of colicky abdominal pain or bloody stools. Ultimately, he was found to have Meckel’s diverticulum. This is the most common lead point among children, but other causes include polyps, small bowel lymphoma, and vascular malformations [5].

 Figure 2. Elongated soft tissue mass. Case courtesy of A.Prof Frank Gaillard,  radiopaedia.org

Figure 2. Elongated soft tissue mass. Case courtesy of A.Prof Frank Gaillard, radiopaedia.org

Diagnostic Testing

Plain abdominal radiographs are not sufficient to rule out intussusception, but they can be useful to exclude perforation and ensure that non-operative reduction by enema is safe.  Some signs of intussusception on abdominal x-ray include an elongated soft tissue mass (classically in the right upper quadrant as in Figure 2) and/or an absence of gas is the distal collapsed bowel, consistent with bowel obstruction.

The optimal diagnostic test for intussusception depends on the patient’s presentation. When infants or toddlers present classically with intermittent severe abdominal pain and no signs of peritonitis, air or contrast enema is the study of choice because it is both diagnostic and therapeutic (Figure 3).

 Figure 3. Intussusception treat with air enema. Case courtesy of Dr Andrew Dixon,  radiopaedia.org

Figure 3. Intussusception treat with air enema. Case courtesy of Dr Andrew Dixon, radiopaedia.org

When the diagnosis is unclear, however, abdominal ultrasound is preferred. Ultrasound has been shown to be 97.9% sensitive and 97.8% specific for diagnosing ileocolic intussusception, and is increasingly becoming the initial diagnostic study of choice at some institutions [6,7]. In addition to the ultrasound finding of “crescent in a donut” shown above, other sonographic signs of intussusception include the “target sign” (Figure 4) and the “pseudokidney sign” (Figure 5).

 Figure 4. Target Sign. Transverse view of the intestinal intussusception. The hyperechoic rings are formed by the mucosa and muscularis, and the hypoechoic bands are formed by the submucosa. Case courtesy of A.Prof Frank Gaillard,  radiopaedia.org

Figure 4. Target Sign. Transverse view of the intestinal intussusception. The hyperechoic rings are formed by the mucosa and muscularis, and the hypoechoic bands are formed by the submucosa. Case courtesy of A.Prof Frank Gaillard, radiopaedia.org

 Figure 5. Pseudokidney sign. Longitudinal view of intestinal intussusception. This view of the intussuscepted bowel mimics a kidney. Case courtesy of A.Prof Frank Gaillard,  radiopaedia.org

Figure 5. Pseudokidney sign. Longitudinal view of intestinal intussusception. This view of the intussuscepted bowel mimics a kidney. Case courtesy of A.Prof Frank Gaillard, radiopaedia.org

Treatment

Without clinical or radiographic signs of perforation, non-operative reduction is first-line treatment. Operative intervention is indicated when the patient is acutely ill, has a lead point needing resection, or the intussusception is in a location unlikely to respond to non-surgical management. For example, small bowel intussusceptions are less likely than ileocolic intussusceptions to respond to non-operative techniques [8].  


CASE CONCLUSION

The patient was taken emergently to the OR, where he underwent exploratory laparoscopy with laparoscopic appendectomy and resection of a Meckel’s diverticulum. No intussusception was noted intraoperatively.  He recovered well, and was discharged home two days later.


A BIT MORE ABOUT MECKEL’S DIVERTICULUM

Meckel’s diverticulum is the most common congenital anomaly of the GI tract. It is a true diverticulum (meaning it contains all layers of the abdominal wall) that is a persistent remnant of the omphalomesenteric duct, which connects the midgut to the yolk sac of the fetus. The “rule of twos” is the classic mnemonic to recall some other important features: it occurs in approximately 2% of the population; the male-to-female ratio is 2:1; it most often occurs within 2 feet the ileocecal valve; it is approximately 2 inches in size; and 2-4% of patients will develop complications related to Meckel’s diverticulum (such as intussusception), usually before age 2 [9].


TAKEAWAY POINTS

  • Consider intussusception in older patients. While it is less likely, approximately 10% of cases occur in patients over 5 years old.

  • In older patients, suspect pathological lead points, such as Meckel’s diverticulum, as potential etiologies of intussusception.

  • Obtain an abdominal x-ray before performing diagnostic/therapeutic enema to rule out perforation.

  • Ultrasound is the preferred test when the diagnosis is uncertain.

  • Patients with small bowel intussusceptions or known lead points are less likely to respond to non-operative reduction.

  • Patients who are acutely ill-appearing require surgery as first-line treatment.


Faculty Reviewer: Dr. Jane Preotle


SOURCES

  1. Intussusception: clinical presentations and imaging characteristics.. Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/22929138

  2. Adenovirus infection and childhood intussusception. - NCBI. Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/1415074

  3. Surgical approach to intussusception in older children: influence of .... Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/25840080

  4. The clinical implications of non-idiopathic intussusception. - NCBI. Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/9880737

  5. The leadpoint in intussusception. - NCBI. Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/2359000

  6. Pediatric Emergency Medicine-Performed Point-of-Care Ultrasound. Retrieved June 22, 2018, from http://www.annemergmed.com/article/S0196-0644(17)31265-9/fulltext

  7. Comparative Effectiveness of Imaging Modalities for the Diagnosis .... Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/28268146

  8. Small bowel intussusception in symptomatic pediatric patients - NCBI. Retrieved June 22, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/11910476

  9. Sagar, Jayesh, Vikas Kumar, and D. K. Shah. "Meckel's diverticulum: a systematic review." Journal of the Royal Society of Medicine 99, no. 10 (2006): 501-505.