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Abstract: A 38-year-old female patient presented to our hospital with lower abdominal pain that had been aggravated for 7 days for 2 years. After physical examination, ultrasound examination and abdominal dissection, the patient was basically identified as having chronic tubal inflammation, and was then given intravenous fluids to replenish body fluids and anti-inflammatory treatment.
Basic information】Female, 38 years old
Disease Type】Chronic tubal inflammation
Hospital】Guangzhou Huadu District People’s Hospital
Date of consultation】October 2020
Treatment plan】Surgical treatment (bilateral salpingo-oophorectomy) + intravenous infusion (sodium chloride glucose injection + ceftriaxone sodium for injection + metronidazole injection)
[Treatment period] 10 days of hospitalization, 1 month of postoperative review
Treatment effect]: The symptoms of discomfort have decreased significantly and the disease has gradually recovered.
I. Initial consultation
Patient Ms. Li, 38 years old, visited the clinic with recurrent lower abdominal pain for 2 years, aggravated for 7 days.G2P1, normal menstrual flow, regular menstruation and oral contraception with short-acting contraceptives. For the past 2 years, she has been suffering from recurrent lower abdominal pain, which was diagnosed as adnexitis and relieved by oral medication, but the pain worsened after stopping the medication or after intercourse or during menstruation. In the past 7 days, the pain in the lower abdomen has increased, along with a feeling of anal cramping and increased vaginal discharge.
The patient was in good general condition, with normal development, no anemic appearance, no abnormal cardiopulmonary auscultation, flat and soft abdomen, positive lower abdominal pressure pain, but no rebound pain. Gynecological examination: vaginal discharge was increased, yellow in color, vaginal mucosa was not congested and edematous, and localized first degree cervical erosion. The patient’s uterus was normal in anterior position, with normal activity and no obvious pressure pain, and a cystic mass of about 4cm×2cm×2cm was palpated in the right adnexal area. The laboratory tests for gynecological tumor markers were normal, and the white blood cell count was 11.6×10＾9/L.
II. Treatment history
The preliminary diagnosis of bilateral hydrosalpinx was made. Since the effect of intravenous medication was not obvious and the patient requested surgical treatment, the patient was given an epidural anesthesia under caesarean section after perfecting the preoperative examinations, and during the operation, it was seen that bilateral hydrosalpinx was obviously swollen, the surface was smooth and not broken, and no abnormality was seen in the uterus, so both tubes were removed and sent for pathological examination.
After surgery, the patient was given intravenous sodium chloride glucose injection to replenish body fluids and electrolytes, and was given a combination of Ceftriaxone sodium for injection and metronidazole injection for anti-inflammatory treatment.
III. Treatment effect
The patient was exhausted 48 hours after the operation, indicating that the abdominal pain gradually decreased, and the vital signs showed that the patient’s body temperature was normal, respiration was stable, and blood pressure and pulse were normal. Physical examination showed that the patient’s lower abdomen was flat and soft, without pressure pain and rebound pain, and without anal swelling, and the patient’s body gradually recovered. The stitches were removed 7 days after the operation, and the patient’s incision healed in stage 1 without infection or blood leakage.
IV. Notes
We are glad that the patient’s condition has improved. We suggest that the patient should rest in bed after discharge and strengthen the local care of the abdominal wound, and the dressing should be removed only after the local crust has fallen off. Once the wound appears abnormal exudation promptly seek medical attention. The diet should be nutritious, but mainly light, no spicy and sour food, less oily food, but protein, vitamin food, and keep the bowel movement smooth.
Keep the vulva clean, scrub it with iodophor twice a day, do not take a bath or have sex for one month, and follow up one month after the operation.
V. Personal insight
Chronic tubal infection is one of the common inflammatory diseases in gynecology. Since the tubal lumen is relatively thin, once inflammation occurs, it will lead to blockage of the fallopian tubes, so the exudate of inflammation cannot be eliminated, so the formation of fluid in the fallopian tubes leads to repeated lower abdominal pain. About 90% of cancers in the fallopian tubes are caused by inflammation of the fallopian tubes, so chronic inflammation of the fallopian tubes should be treated actively. In this case, the patient did not require pregnancy and had recurrent episodes of chronic tubal inflammation for 3 years, so it was recommended to remove both fallopian tubes.