A low-grade fever is generally present, but the temperature may be normal. High temperatures are typically seen with appendiceal perforation. Local tenderness is usually elicited on palpation of the right lower quadrant (McBurney point). The appearance of severe generalized muscle guarding, abdominal rigidity, rebound tenderness, right-sided mass, tenderness on rectal examination, positive psoas sign (pain with forced hip ﬂexion or passive extension of hip), and obturator signs (pain with passive internal rotation of ﬂexed thigh) indicate appendicitis. The pelvic examination usually does not show cervical motion or bilateral adnexal tenderness, but right-sided unilateral adnexal area tenderness can be present.
Many patients with acute appendicitis have normal total leukocyte counts but a left shift is usually present. Ultrasound examination of the pelvic organs is normal, whereas the appendix may appear abnormal on ultrasound or CT with contrast. CT with oral contrast with normal filling of the appendix rules out appendicitis. Diagnostic laparoscopy can be useful to rule out other sources of pelvic pathology, but it may be difficult to visualize the appendix sufficiently to rule out early appendiceal inﬂammation, so appendectomy can be indicated if the diagnosis is uncertain.
Initial management is intravenous administration of ﬂuids, strict restriction of any oral intake, and preoperative antibiotics followed by laparoscopy or laparotomy. Surgery with a false-positive rate of 15% is considered acceptable and is preferable to prolonged observation with the risk of rupture and peritonitis. Not only is a ruptured appendix life threatening, but it can have profound consequences for the fertility of women of reproductive age. With the advent of imaging, negative appendectomy rates are less than 10% (29).
Acute Diverticulitis Acute diverticulitis is a condition in which there is inﬂammation of a diverticulum or outpouching of the wall of the colon, usually involving the sigmoid colon. Diverticulitis typically affects postmenopausal women but can occur in women during their 30s and 40s.
The severe, left lower quadrant pain of diverticulitis can occur following a long history of symptoms of irritable bowel (bloating, constipation, and diarrhea), although diverticulosis usually is asymptomatic. Diverticulitis is less likely to lead to perforation and peritonitis than is appendicitis. Fever, chills, and constipation typically are present, but anorexia and vomiting are uncommon.
Bowel sounds are hypoactive and are substantially decreased with peritonitis related to a ruptured diverticular abscess. Abdominal examination reveals distention with left lower quadrant tenderness on direct palpation and localized rebound tenderness. Abdominal and bimanual rectovaginal examinations may reveal a poorly mobile, doughy inﬂammatory mass in the left lower quadrant. Leukocytosis and fever are common. Stool guaiac may be positive as a result of inﬂammation of the colon or microperforation.
CT with and without contrast is an important adjunct to history and physical examination (30). It will reveal a swollen, edematous bowel and can rule out an abscess. A barium enema is contraindicated. Diverticulitis is initially managed medically with intravenous administration of ﬂuids, strict restriction of oral intake, and broad-spectrum intravenous antibiotics. A diverticular abscess, obstruction, fistula, or perforation requires general surgical intervention.
Intestinal Obstruction The most common causes of intestinal obstruction in women are postsurgical adhesions, hernia formation, inﬂammatory bowel disease, or carcinoma of the bowel or ovary.