Physical exam: <\/strong>\u00a0The patient was well-appearing but uncomfortable. Her abdomen was soft with mild distention and diffuse tenderness, with voluntary guarding on deep palpation. No CVA tenderness was appreciated.<\/p>\n\n\n\n Labs:<\/strong> Hgb 11.3, WBC 18.7, Negative urine pregnancy test, lactate WNL, Urinalysis negative<\/p>\n\n\n\n Bedside Ultrasound<\/strong>:<\/p>\n\n\n\n A CT scan was ordered which showed a hemorrhagic ovarian cyst with mild hemoperitoneum. OBGYN was consulted and recommended no acute surgical intervention. They recommended fluids and outpatient follow-up with repeat ultrasound of right ovarian cyst at 6 weeks.<\/p>\n\n\n\n Discussion:<\/strong><\/p>\n\n\n\n Acute pelvic pain in reproductive-age women represents a broad differential diagnosis including appendicitis, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, and ruptured ovarian cyst. Point-of-care ultrasound (POCUS) serves as an essential early diagnostic tool because it is rapid, radiation free, and able to identify adnexal pathology and free intraperitoneal fluid even before CT imaging is obtained.<\/p>\n\n\n\n Hemorrhagic ovarian cysts are typically functional cysts resulting from bleeding into a corpus luteum or follicular cyst. Sonographically, they often demonstrate reticular internal echoes, a lacy or fibrin-strand appearance, or a mixed echogenicity depending on the age of the clot.1,2<\/sup> Cyst rupture is more likely if the cyst is 5 cm or greater. Color flow can be used to evaluate for active extravasation. Symptoms accompanying rupture include sudden severe abdominal pain or near syncope. Free fluid may be present in the pelvis, with swirling sometimes visible for brisk bleeds. Transvaginal POCUS is highly sensitive for detecting free intraperitoneal fluid of as little as 10cc, making it a valuable adjunct when evaluating patients with suspected hemoperitoneum.3<\/sup><\/p>\n\n\n\n In this case, the adnexal mass with internal echoes and associated free fluid on POCUS raised concern for a hemorrhagic cyst with rupture, prompting timely gynecologic consultation and confirming findings on CT.<\/p>\n\n\n\n Hemorrhagic cysts frequently mimic appendicitis due to overlapping localization of pain and peritoneal irritation. Studies show that up to 20-30% of reproductive-age women evaluated for appendicitis ultimately have a gynecologic etiology, underscoring the importance of early pelvic imaging.4<\/sup> The patient\u2019s leukocytosis and focal RLQ tenderness initially broadened the differential, but POCUS rapidly narrowed the diagnosis.<\/p>\n\n\n\n Most hemorrhagic ovarian cysts are self-limited and managed conservatively with pain control and follow-up imaging.5<\/sup> Indications for intervention include hemodynamic instability, large-volume hemoperitoneum, or concern for ovarian torsion. In this case, the patient remained stable, with moderate hemoperitoneum on CT and no evidence of torsion or persistent bleeding. Oftentimes with cyst rupture, repeat CBC is indicated to evaluate for ongoing blood loss.<\/p>\n\n\n\n POCUS is a recommended first-line tool in the evaluation of acute pelvic pain in the emergency department. The American College of Emergency Physicians notes the utility of pelvic ultrasound for identifying adnexal masses, cyst rupture, free fluid, and excluding ectopic pregnancy in reproductive-age females.6 <\/sup> While transvaginal ultrasound is the standard of care for evaluation of the ovaries, transabdominal POCUS is highly effective in early triage and in resource-limited or time-sensitive settings.<\/p>\n\n\n\n This case demonstrates the significant diagnostic value of POCUS in identifying adnexal pathology early in the clinical course, guiding appropriate consultation, and avoiding unnecessary CT radiation. Recognition of characteristic sonographic features of hemorrhagic ovarian cysts empowers emergency physicians to differentiate benign from life-threatening causes of pelvic pain.<\/p>\n\n\n\n References:<\/p>\n\n\n\n\n
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