A Decision About an Incision.

It's one of the most difficult clinical decisions we have to make: A patient in the emergency room may have pelvic inflammatory disease. Should you perform diagnostic laparoscopy?

On the one hand, we don't like to operate on unprepared patients we don't know; on the other hand, there are short-and long-term consequences in making the wrong diagnosis.

When faced with a diagnostic dilemma between PID and other causes of acute pelvic pain, relying on an ultrasound diagnosis is one of the biggest mistakes a physician can make. This is especially true if the physician does not view the films but just reads the report of the radiologist, which often says something like "possible pelvic inflammatory disease" or "possible appendicitis."

There are no pathognomonic signs of PID on ultrasound, so the radiologist often lists all of the possible causes of a set of nonspecific pelvic findings on ultrasound. Obviously, these are usually the same causes that you have already considered clinically.

Surgery is indicated for possible pelvic inflammatory disease in a few specific situations. One is the patient whose diagnosis is uncertain. A significant percentage of patients who present with PID do not have the classic findings, and this presents a problem, especially since the differential diagnosis often includes appendicitis, which is generally best treated by immediate appendectomy.

Laparoscopy is indicated in a patient with possible pelvic inflammatory disease if there is not a rapid clinical response to appropriate medical management. ...