The image shows acute appendicitis (marked by the yellow arrow). CT scan was performed because the patient’s presentation was not consistent with a simple ovarian cyst. Ovarian cysts do not typically cause vomiting when torsion is not present.  

Discussion

Ovarian cysts typically present with unilateral pelvic pain that may radiate to the ipsilateral anterior thigh. Pain often starts abruptly if rupture or torsion occurs. Vomiting is uncommon unless ovarian torsion is present, but diarrhea may occasionally occur.


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Ultrasound is the imaging study of choice for pelvic structures. Simple cysts <2.5 cm are considered functional (physiologic) and usually do not cause acute pain; therefore, other conditions should be considered when a cyst of this size is discovered. Larger or complex cysts are often painful, especially with rupture, which may manifest on ultrasound as free fluid in the pelvis. Cysts >5 cm are at higher risk for torsion. 

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Pain medication taken for ≤7 days is the mainstay of treatment for most ovarian cysts, and pain typically resolves gradually during this period of time. For complex or larger cysts, repeat ultrasound performed within 6 to 8 weeks is recommended to document resolution. Indications for admission are rare but include suspicion of torsion or hemoperitoneum from severe bleeding. 

It is important to note that many ovarian cysts are not painful; therefore, if the clinical presentation does not align with the diagnosis of one, an ovarian cyst may be an incidental finding (similar to cholelithiasis and some findings on urinalysis), while the real pathology is elsewhere in the abdomen. 

Conclusion

The patient was admitted and underwent an appendectomy for an unruptured appendix.

Table. Ovarian Cyst

Symptoms Pain is usually unilateral, often begins mid-cycle, and ends by menses.
Cyst types • Functional: simple, <2.5 cm
• Pathologic: complex or >2.5 cm
• Worry: >5 cm (increased risk for torsion)
Treatment • Discharge home; administer pain medication for up to 7 days and repeat ultrasound within 6 to 8 weeks if complex cyst or 6 to 12 weeks if simple cyst.
• Consider hospital admission if international normalized ratio increased, hemoglobin decreased, visible or large amount of free fluid on ultrasound, cyst size >5 cm, fever, change in vital signs, nausea or vomiting, or unsure of diagnosis.
Pearl Cysts are often painless unless bleeding, rupture, or torsion occurs.

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Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. EMresource.org. 2017;5.

This article originally appeared on Clinical Advisor