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Young Girl With Abdominal Pain
IMAGES IN EMERGENCY MEDICINE Huan-Wen Hsu, MD; Ying-Hock Teng, MD, PhD; Chao-Bin Yeh, MD, PhD; Sai-Wai Ho, MD 0196-0644/$-see front matter Copyright © 2017 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2017.04.025
Figure 1. Transabdominal ultrasonographic view of the right lower quadrant, demonstrating a cystic mass with 1-cm wall thickening.
Figure 2. Ultrasonographic view showing absent kidney in right hepatorenal fossa (star) between the liver (X) and psoas muscle (cross) (left panel). Normal contralateral left kidney (asterisk) (right panel).
Figure 3. Coronal CT of the abdomen, demonstrating right renal agenesis (white arrow) and uterus didelphys (black arrows); note the obstructive hematometra in the right hemiuterus.
[Ann Emerg Med. 2017;70:e39-e40.] A 15-year-old girl presented to the emergency department (ED) with progressive right lower quadrant abdominal pain for 2 days shortly after menarche. She had no vomiting or diarrhea. On examination, she was afebrile, with marked right lower quadrant abdominal tenderness without peritoneal signs. Blood test results were negative. Abdominal ultrasonography revealed a cystic mass over the right lower abdominal quadrant (Figure 1) and right renal agenesis (Figure 2), and computed tomography (CT) was subsequently performed (Figure 3).
For the diagnosis and teaching points, see page e40. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 70, no. 4 : October 2017
Annals of Emergency Medicine e39
Hsu et al
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e39)
DIAGNOSIS: Herlyn-Werner-Wunderlich syndrome. Herlyn-Werner-Wunderlich syndrome is a rare congenital anomaly of the Müllerian duct system, with an incidence of approximately 0.1% to 3.8%, which manifests the triad of uterus didelphys, ipsilateral renal agenesis, and obstructed hemivagina.1-3 Clinical symptoms and signs are nonspecific, including lower abdominal pain, dysmenorrhea, and palpable abdominal mass. These conditions may relate to the ipsilateral hematometra resulting from enduring menstrual flow in the obstructed vagina.4 Elective surgery is the best treatment option; however, oral contraceptives with analgesics can serve as a temporary conservative treatment.5 In the ED, early recognition and prompt intervention can improve patients’ quality of life and prevent complications such as endometriosis or infertility. Ipsilateral painful pelvic mass and renal agenesis are indicative of this diagnosis. Author affiliations: From the Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan (Hsu, Teng, Yeh, Ho); and the Department of Emergency Medicine (Hsu, Teng, Yeh, Ho) and Institute of Medicine (Hsu, Ho), Chung Shan Medical University, Taichung, Taiwan. REFERENCES 1. Zurawin RK, Dietrich JE, Heard MJ, et al. Didelphic uterus and obstructed hemivagina with renal agenesis: case report and review of the literature. J Pediatr Adolesc Gynecol. 2004;17:137-141. 2. Burgis J. Obstructive Mullerian anomalies: case report, diagnosis, and management. Am J Obstet Gynecol. 2001;185:338-444. 3. Orazi C, Lucchetti MC, Schingo PM, et al. Herlyn-Werner-Wunderlich syndrome: uterus didelphys, blind hemivagina and ipsilateral renal agenesis. Sonographic and MR findings in 11 cases. Pediatr Radiol. 2007;37:657-665. 4. Jeong J-H, Kim Y-J, Chang C-H, et al. A case of Herlyn-Werner-Wunderlich syndrome with recurrent hematopyometra. J Womens Med. 2009;2:77-80. 5. Del Vescovo R, Battisti S, Di Paola V, et al. Herlyn-Werner-Wunderlich syndrome: MRI findings, radiological guide (two cases and literature review), and differential diagnosis. BMC Med Imaging. 2012;12:4.
e40 Annals of Emergency Medicine
Volume 70, no. 4 : October 2017
Figure 1. Transabdominal ultrasonographic view of the right lower quadrant, demonstrating a cystic mass with 1-cm wall thickening.
Figure 2. Ultrasonographic view showing absent kidney in right hepatorenal fossa (star) between the liver (X) and psoas muscle (cross) (left panel). Normal contralateral left kidney (asterisk) (right panel).
Figure 3. Coronal CT of the abdomen, demonstrating right renal agenesis (white arrow) and uterus didelphys (black arrows); note the obstructive hematometra in the right hemiuterus.
[Ann Emerg Med. 2017;70:e39-e40.] A 15-year-old girl presented to the emergency department (ED) with progressive right lower quadrant abdominal pain for 2 days shortly after menarche. She had no vomiting or diarrhea. On examination, she was afebrile, with marked right lower quadrant abdominal tenderness without peritoneal signs. Blood test results were negative. Abdominal ultrasonography revealed a cystic mass over the right lower abdominal quadrant (Figure 1) and right renal agenesis (Figure 2), and computed tomography (CT) was subsequently performed (Figure 3).
For the diagnosis and teaching points, see page e40. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 70, no. 4 : October 2017
Annals of Emergency Medicine e39
Hsu et al
Images in Emergency Medicine
IMAGES IN EMERGENCY MEDICINE (continued from p. e39)
DIAGNOSIS: Herlyn-Werner-Wunderlich syndrome. Herlyn-Werner-Wunderlich syndrome is a rare congenital anomaly of the Müllerian duct system, with an incidence of approximately 0.1% to 3.8%, which manifests the triad of uterus didelphys, ipsilateral renal agenesis, and obstructed hemivagina.1-3 Clinical symptoms and signs are nonspecific, including lower abdominal pain, dysmenorrhea, and palpable abdominal mass. These conditions may relate to the ipsilateral hematometra resulting from enduring menstrual flow in the obstructed vagina.4 Elective surgery is the best treatment option; however, oral contraceptives with analgesics can serve as a temporary conservative treatment.5 In the ED, early recognition and prompt intervention can improve patients’ quality of life and prevent complications such as endometriosis or infertility. Ipsilateral painful pelvic mass and renal agenesis are indicative of this diagnosis. Author affiliations: From the Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan (Hsu, Teng, Yeh, Ho); and the Department of Emergency Medicine (Hsu, Teng, Yeh, Ho) and Institute of Medicine (Hsu, Ho), Chung Shan Medical University, Taichung, Taiwan. REFERENCES 1. Zurawin RK, Dietrich JE, Heard MJ, et al. Didelphic uterus and obstructed hemivagina with renal agenesis: case report and review of the literature. J Pediatr Adolesc Gynecol. 2004;17:137-141. 2. Burgis J. Obstructive Mullerian anomalies: case report, diagnosis, and management. Am J Obstet Gynecol. 2001;185:338-444. 3. Orazi C, Lucchetti MC, Schingo PM, et al. Herlyn-Werner-Wunderlich syndrome: uterus didelphys, blind hemivagina and ipsilateral renal agenesis. Sonographic and MR findings in 11 cases. Pediatr Radiol. 2007;37:657-665. 4. Jeong J-H, Kim Y-J, Chang C-H, et al. A case of Herlyn-Werner-Wunderlich syndrome with recurrent hematopyometra. J Womens Med. 2009;2:77-80. 5. Del Vescovo R, Battisti S, Di Paola V, et al. Herlyn-Werner-Wunderlich syndrome: MRI findings, radiological guide (two cases and literature review), and differential diagnosis. BMC Med Imaging. 2012;12:4.
e40 Annals of Emergency Medicine
Volume 70, no. 4 : October 2017