Correspondence

A pregnant woman presenting to the ED with Valentino’s syndrome

To the Editor,

Pregnant patients with acute abdominal pain can pose a diagnostic and therapeutic puzzle for the emergency department (ED) physician. The general reluctance to use conventional radiographic study and the modification of both symptoms and signs because of anatomic and physiologic alterations caused by pregnancy may delay or mislead the diagnosis. Peptic ulcer in pregnancy is rare, and acute perforation is even more rare. Perforated peptic ulcer in pregnancy can be miserable to both mother and fetus if not promptly recognized and timely remedied. The following is a case with Valentino’s syndrome-Unusual presentation of perforated peptic ulcer at ED.

A 23-year-old woman in the 20th week of gestation visited our ED with the complaint of abdominal pain in the right lower quadrant (RLQ) for 3 days. She had a history of Duodenal ulcer without any treatment. The pain was initially in the epigastric area for 1 day and then shifted to the RLQ in the following 3 days. The character of the pain was persistent but not cramping. There was no fever, diarrhea, and constipation. She denied any other systemic diseases, major operations, daily medication, or history of allergy. On physical examination, vital signs revealed only a heart rate of 119 beats per minute. The abdomen was soft, but there was tenderness and rebound tenderness in the RLQ area and epigastric area. The degree of tenderness in the RLQ was more severe than in the epigastric area. The obturator sign was present, but psoas and Rovsing’s sign were absent. The bowel sounds were hypoactive.

Laboratory data revealed a white blood cell count of

11.9 x 10³/lL with 77% neutrophils and 5% bands, hemoglobin level of 11.5 g/dL, and platelet count of 154 x 10³/lL. Emergency ultrasonography revealed small

amounts of fluid accumulation around the cecum without obvious tubular structure and abnormal gynecologic finding. With acute appendicitis suspected clinically by the surgeon, she underwent appendectomy via the McBur- ney incision. During the operation, turbid ascites approx- imately 50 mL was aspirated, but unexpectedly, the appendix was grossly normal. The surgeon performed a

laparotomy, and a 0.3 x 0.3 centimeter sealed-off perforated duodenal ulcer on the anterior wall of the bulb was detected. The appendix revealed periappendicitis in the pathological report. The postoperative course of the mother and fetus was uneventful. She was discharged from the hospital 12 days after admission.

Gastrointestinal surgical problems occur in approximate- ly 0.5% to 1% of all pregnancies [1]. Peptic ulcer disease is uncommon in pregnancy. A reduction in gastric acid secretion and gut motility combined with increased mucus production has been proposed as the explanation [2,3]. Acute complications of peptic ulcer, such as perforation, in pregnancy are more rarely encountered. The manifestation of perforated peptic ulcer is sudden, sharp, and severe abdominal pain. At first, it is located in the epigastrium but quickly spreads over the entire abdomen, especially along the right side of the abdomen, as the chemical peritonitis. When the duodenal contents descend to the right pericolic gutter, it can mimic appendicitis (Valentino’s syndrome) [4]. Physical examination may reveal rebound tenderness and guarding of the abdomen. Laboratory study findings reveal leukocytosis. An erect abdominal radiograph may demon- strate gas under the diaphragm [5]. Because of the hesitancy of radiographic studies during pregnancy, and the low incidence of the disease and similar symptoms in healthy pregnant women, the diagnosis of perforated peptic ulcer can be difficult. The mortality rate in these patients is high, and the fatal outcome appears because of late diagnosis and operation. Acute appendicitis is the leading cause of the acute abdomen in pregnancy, occurring in approximately 1 in 1000 to 1500 pregnancies [6,7]. Appendicitis typically presents as epigastric or periumbilical pain and the pain migrated to RLQ, the single most reliable symptom [6]. The accuracy of clinically preoperative diagnosis of appendicitis in pregnancy ranges from approximately 60% to 80% [8,9]. The ultrasonography is a good tool to assist us to diagnose acute appendicitis in pregnant women at ED. If the appendix appears normal during operation, it is crucial to search for other causes [5,6].

According to the presentations, imaging studies in our patient and disease prevalence, we reasonably suspected acute appendicitis. However, actually these presentations were also Valentino’s syndrome in pregnancy. On reviewing the literature, this was nearly never been reported in

0735-6757/$ - see front matter D 2005 doi:10.1016/j.ajem.2004.04.037

218 Correspondence

pregnant women before. In summary, if a pregnant patient with peptic ulcer history suffers from acute RLQ pain, ultrasonography demonstrates pericecal fluid accumulation without obvious blindended tubular structure, despite rarity, Valentino’s syndrome should be taken into consideration.

References

1. Firstenberg MS, Malangoni MA. Gastrointestinal surgery during pregnancy. Gastroenterol Clin North Am 1998;27(1):73 - 88.
2. Cunningham FG, McCubbin JH. Appendicitis complicating pregnancy. Obstet Gynecol 1975;45:415.
3. Nathan L, Huddleston JF. Acute abdominal pain in pregnancy. Obstet Gynecol Clin North Am 1995;22(1):55 - 68.
4. Glasgow RE, Mulvihill SJ. Abdominal pain, including the acute abdomen. In: Feldman M, Friedman LS, Sleisenger MH, editors. Gastrointestinal and liver disease. 7th ed. Philadelphia7 Saunders; 2002. p. 78.
5. Sivanesaratnam V. The acute abdomen and the obstetrician. Baillieres Best Pract Res Clin Obstet Gynaecol 2000;14(1):89 - 102.
6. Sharp HT. The acute abdomen during pregnancy. Clin Obstet Gynecol 2002;45(2):405 - 13.
7. Cappell MS, Friedel D. Abdominal pain during pregnancy. Gastreoen- terol Clin North Am 2003;32(1):1 - 58.
8. Weingold AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983;26:801 - 9.
9. Epstein FB. Acute abdominal pain in pregnancy. Emerg Med Clin North Am 1994;12(1):151 - 65.

Chia-Chun Hsu MD Yeuh-Ping Liu MD Wan-Ching Lien MD Ting-I Lai MD

Hsiu-Po Wang MD Department of Emergency Medicine National Taiwan University Hospital

National Taiwan University, College of Medicine

Taipei 100, Taiwan E-mail address: [email protected]