Archives of Academic Emergency Medicine. 2022; 10 (1); e29 PH OTO QU I Z A 27-year-old Female Patient with Acute nausea/vomiting and Pelvic pain; a Photo Quiz Murat Ozsarac1∗, Yusuf Yurumez1, Onur Karakayali1 1. Department of Emergency Medicine, Sakarya University Faculty of Medicine, Sakarya, Turkey. Received: February 2022; Accepted: March 2022; Published online: 24 April 2022 Cite this article as: Ozsarac M, Yurumez Y, Karakayali O. A 27-year-old Female Patient with Acute nausea/vomiting and Pelvic pain; a Photo Quiz. Arch Acad Emerg Med. 2022; 10(1): e29, DOI: https://doi.org/10.22037/aaem.v10i1.1508. Figure 1: Axial view of intravenous contrast-enhanced abdominopelvic computed tomography scan of the patient. 1. Case presentation A 27-year-old female patient, G2P1, presented to the emer- gency department (ED) with acute onset nausea, vomiting, and mild chronic abdominopelvic pain. Physical examina- tion revealed bilateral lower quadrant tenderness without re- bound, guarding, or rigidity, and vital signs were within nor- mal limits. Electrolytes, complete blood count, and liver and kidney function tests were normal. A pregnancy test was neg- ative, and urinalysis did not reveal any abnormalities. No free fluid was observed in the abdominal ultrasound, and the ovaries and other intra-abdominal structures were found to be normal. The patient underwent intravenous contrast- enhanced abdomiopelvic computed tomography (CT) scan (figure 1). What is your diagnosis? 2. Diagnosis Intravenous contrast-enhanced abdominopelviccomputed tomography (CT) scan shows dilatation in the left gonadal vein and dilated vascular structures in the left parauterine area (figure 2) in favor of pelvic congestion syndrome (PCS). The differential diagnosis of pelvic pain is broad. Many etio- logical causes related to gynecological, gastrointestinal, uri- nary, vascular, nervous, and musculoskeletal systems should be considered (1). Pelvic Congestion Syndrome (PCS) might be one of the most common, underdiagnosed causes of pelvic pain in female patients. It is also an entity not suffi- ciently recognized in emergency medicine practice. The eti- ology of congestion is quite complex due to hormonal and structural causes. Valvular insufficiency, reflux, and venous obstruction play an important role in developing congestion and stasis (2). This text presents and discusses a PCS case who presented to the Emergency Department (ED) with ab- dominopelvic pain and nausea/vomiting. 3. Case fate Antiemetics and analgesics were administered. No interven- tion was performed for the patient after consultation with obstetrics and gynecology. A follow-up by the cardiovascular surgery department was planned. The control trans-vaginal ultrasound examination performed at the outpatient clinic two weeks later was evaluated as normal. No malignancy or intraepithelial lesion was observed in the cervical smear. Analgesics were recommended to the patient, and symptom This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Ozsarac et al. 2 Figure 2: Axial view of intravenus contrast-enhanced ab- dominopelvic computed tomography scan demonstrates dilatation in the left gonadal vein and dilated vascular structures (white arrow). follow-up was planned. 4. Discussion The diagnosis of PCS does not provide a clue to to understand the underlying mechanism of disorders of the pelvic venous circulations. The clinical manifestations in PCS are chronic pelvic pain lasting longer than six months, aggravated by pro- longed standing, intercourse, and menstruation, as well as lower back pain, urinary symptoms such as dysuria, urgency, frequent urination, and vaginal discharge (3). It typically af- fects young multiparous women between the ages of 20 and 30, although it can rarely be seen in pregnant women and during the postmenopausal period (4). Pelvic varices are ac- companied by lower extremity varices and chronic venous insufficiency in 10%-70% of cases. It is less frequently as- sociated with the enlargement of thigh, perineal, vulvar and saphenous veins. Particularly, the development of edema in the legs, varicose veins of the lower extremities, pain, and heaviness in the legs are directly related to the reflux that de- velops in common anatomical connections (5). As a non- invasive screening tool, Doppler ultrasound is a reasonable initial option as it allows real-time dynamic imaging and flow evaluation. Transvaginal ultrasound and Doppler ultrasound criteria for PCS diagnosis include a dilated, parauterine, and paraovarian vein greater than 4 mm in diameter or retro- grade flow (1, 4). Color Doppler in the upright position with Valsalva manuver significantly increases the diagnostic accu- racy (1). PCS imaging criteria for CT and magnetic resonance imaging (MRI) include the presence of at least four ipsilat- eral coiled parauterine vessels or an ovarian vein diameter greater than 8 mm (4). CT and MRI are better diagnostic tools than ultrasound as they provide a detailed anatomical exam- ination of dilated pelvic and ovarian veins. However, CT and MRI cross-sectional images obtained in supine position play a limited role in diagnosing PCS and detecting dilatation of the thin pelvic veins (6). Once the diagnosis is confirmed, PCS management includes medical, surgical, and endovas- cular approaches. Different treatment modalities have been tried for embolization of abnormal pelvic veins, providing symptom relief in 75% of patients (5). 5. Conclusion Contrast-enhanced CT scan may provide an incidental diag- nosis of PCS in patients with frequent presentations due to pelvic pain. However, the diagnosis can be easily overlooked unless Doppler ultrasonography is performed in the semi- supine or upright position. Emergency physicians must rec- ognize this common but overlooked clinical condition. 6. Declarations 6.1. Acknowledgements We would like to thank Lingus and BSB group for English lan- guage editing. 6.2. Conflict of interest The authors declare no conflicts of interest. 6.3. Funding and support None. 6.4. Authors’ contributions All authors met the criteria for authorship contribution based on the international committee of medical journal editors’ recommendations. 6.5. Informed consent for publication The photo quiz was written in an anonymous characteristic, thus confidential and detailed data about the patient is re- moved. Editor and reviewers can know and see these detailed data. References 1. Bendek B, Afuape N, Banks E, Desai NA. Comprehen- sive review of pelvic congestion syndrome: causes, symp- toms, treatment options. Curr Opin Obstet Gynecol. 2020;32(4):237-42. 2. Gavrilov S, Moskalenko YP. Does pelvic congestion syn- drome influence symptoms of chronic venous disease of the lower extremities? Eur J Obstet Gynecol Reprod Biol. 2019;243:83-6. 3. Liu J, Han L, Han X. The effect of a subsequent pregnancy after ovarian vein embolization in patients with infertil- ity caused by pelvic congestion syndrome. Acad Radiol. 2019;26(10):1373-7. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10 (1); e29 4. Bartl T, Wolf F, Dadak C. Pelvic congestion syndrome (PCS) as a pathology of postmenopausal women: a case report with literature review. BMC Women’s Health. 2021;21(1):181. 5. Basile A, Failla G, Gozzo C. Pelvic Congestion Syndrome. Semin Ultrasound CT MR. 2021;42(1):3-12. 6. Borghi C, Dell’Atti L. Pelvic congestion syndrome: the current state of the literature. Arch Gynecol Obstet. 2016;293(2):291-301. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Case presentation Diagnosis Case fate Discussion Conclusion Declarations References