Ventriculoperitoneal (VP) blow malfunctions and complications are accepted presentations to pediatric emergency departments (ED), as is belly affliction in boyish females; however, belly affliction is not usually a affirmation of blow malfunction. The accepted presenting actualization of VP blow malfunctions are cephalalgia and vomiting, although the abstract cites assorted aberrant presentations, including ascites, belly pseudocysts, scrotal edema, and nonvisceral penetrations. We address a case of a 16-year-old changeable accommodating with a VP blow who presented to the pediatric ED with headache, belly pain, and abounding bright vaginal discharge. At laparoscopy, the distal end of the patient’s VP blow was begin to be clarification into a loculated accumulation encasing a appropriate hydrosalpinx.
A.M., a 16-year-old white female, presented to the Medical University of South Carolina pediatric ED in backward July 1999 with a 2-week history of added abounding bright vaginal acquittal and a 1-day history of astringent lower belly pain, headache, nausea, and agitation to 101.2°F. She denied vomiting, diarrhea, constipation, or urinary symptoms. Her aftermost menstrual aeon was 3 weeks above-mentioned to presentation, and the accommodating denied any animal activity. About 1 anniversary above-mentioned to the accepted admission, the accommodating was apparent by a gynecologist for the vaginal discharge. She had a accustomed pelvic examination, accustomed vaginal beard microscopy, and abrogating endocervical cultures. The butt of her analysis of systems was negative.
Relevant accomplished medical history included VP blow adjustment in January 1999 for pseudotumor cerebri with assiduous occipital headaches. The anaplasty followed abortion of bourgeois administration over several months, including analysis with lumbar puncture, and medications including diuretics. The accommodating underwent two blow revisions for bulging attic sutures. At a altered institution, she had additionally had a analytic laparoscopy with accidental appendectomy in 1996, and a consecutive laparoscopic appropriate ovarian cystectomy in March 1999 at our institution. Oral contraceptives were assigned for abolishment of ovarian cyst accumulation at that time, but were discontinued a abbreviate time after by the accommodating herself.
On examination, the accommodating was a well-developed teenager, active and cooperative, but in abstinent ache from belly affliction and the apparent bulk of vaginal discharge. Vital signs were normal. Her belly assay appear mild, broadcast amore with autonomous absorption but after rebound. The belly was bendable and nondistended with accustomed bowel sounds. There was no hepatosplenomegaly or added apparent mass. Best arresting was the ample basin of bright vaginal acquittal that blood-soaked the assay table. Results of the blow of the antecedent examination, including head, blow reservoir, pupil, and neurologic examinations, were normal.
Pelvic assay appear accustomed alien genitalia, accustomed vaginal tissues, a baby nulliparous cervix, and profuse, clear, adulterated cervical acquittal that formed a basin in the after vaginal fornix. Bimanual assay appear abstinent cervical motion tenderness. Palpation of the pelvic structures was bound by autonomous guarding; however, a adequateness was acclaimed in the appropriate adnexa. Gram stain and wet arise microscopy appear accustomed epithelial beef and no affirmation of infection. Potassium hydroxide alertness (KOH prep) was abrogating for fungal elements.
A transvaginal ultrasound appear a normal-sized uterus; however, the endometrial atrium independent sonolucent aqueous throughout the fundus, body, cervix, and both cornu. The bulk of aqueous amplification fluctuated during the study. Free aqueous was additionally acclaimed in the peritoneal cavity. The appropriate ovary abstinent 4.5 × 2.5 × 3.5 cm and independent assorted cysts, at atomic one of which independent septations and centralized debris. This was believed to represent a hemorrhagic cyst. The larboard ovary was 2.7 × 1.2 × 2.2 cm with a accustomed appearance. Both ovaries were able-bodied perfused.
Laboratory testing appear a accustomed blow series, with distal tip above the appropriate accurate pelvis, abrogating serum abundance test, accustomed basal metabolic panel, accustomed borderline white claret corpuscle count, sedimentation bulk of 6l mm/h, and albumin 3.4 mg/dL. Urinalysis showed trace protein, trace blood, abstinent mucus, and abstinent calcium oxalate crystals. Blow aqueous appear no white or red claret cells, glucose 70 mg/dL, and protein 10 mg/dL. The vaginal aqueous showed a creatinine of 0.8 mg/dL, glucose of 48 mg/dL, and no protein.
The accommodating was accepted brief for ascertainment beneath the analysis of hemorrhagic appropriate ovarian cyst. Her affliction and bulk of vaginal acquittal were somewhat bigger in the morning, and she was absolved on analgesic and nonsteroidal affliction medications with aftereffect in the gynecology dispensary 1 anniversary later. At the time of follow-up, the accommodating appear connected abounding vaginal acquittal and added pain, and she was accepted for surgical management.
Diagnostic laparoscopy appear a accustomed uterus, larboard fallopian tube, and larboard ovary. There was a ample appropriate hydrosalpinx after identifiable fimbria, which was additionally circuitous with close omental adhesions (Fig. 1). The blow tip was not initially visualized. Upon lysis of the omental adhesions, a blitz of bright aqueous was appear from the loculated accumulation of omentum and appropriate adnexal structures. The distal tip of the VP blow was acclaimed to be aural this cystic loculation, abreast the distal fallopian tube. The appropriate ovary was again visualized and acclaimed to be absolutely normal. A appropriate salpingectomy was performed, and the tip of the VP blow was freed. Postoperatively, the accommodating accustomed 48 hours of intravenous antibiotics, her affliction subsided, and her acquittal bound immediately. Over 1 year out, she charcoal asymptomatic and has had no added blow or gynecologic problems. Due to the appropriate salpingectomy and actual appropriate ovary, the gynecology administration continues to
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