Purulent salpingitis: diagnosis

With vaginal examination of patients with acute purulent salpingitis, it is not always possible to obtain objective information due to the sharp soreness and protective tension of the abdominal muscles. Nevertheless, the most typical signs are painfulness when moving behind the cervix, the definition of pastosity or palpable formation of small sizes with fuzzy contours in the appendages, as well as sensitivity in palpation of the lateral and posterior fornix.

It is believed that the criteria for acute inflammation of the pelvic organs are an increase in temperature, increased ESR and the appearance of a C-reactive protein.

Diagnosis of acute purulent salpingitis should be based on the identification of the following three mandatory signs:

• abdominal pain;
• sensitivity when moving behind the cervix;
• sensitivity in the appendages in combination with at least one of the following additional symptoms:
  • temperature exceeding 38 degrees;
  • leukocytosis (more than 10.5 thousand);
  • pus obtained from puncture of the posterior fornix;
  • presence of inflammatory formations in a bimanual or ultrasound study;
  • ESR> 15mm / h.

Symptoms of acute purulent salpingitis are confirmed by laboratory data. In the peripheral blood, the following changes are detected in patients with peripheral blood: leukocytosis up to 10,500 with a moderate shift of the leukocyte formula to the left (6-9% of the rod-shaped leukocytes), an ESR of 20-30 mm / h, and the presence of a sharply positive C-reactive protein .

The decisive role in the favorable outcome is played by the early detection of the process (at the stage of purulent salpingitis) and the early onset of adequate therapy. In addition to clinical and laboratory methods of investigation, the identification of the pathogen is important. The material for the study should be taken from all typical sites, with the most reliable study of the material obtained directly from the tube or cavity of the small pelvis with puncture of the posterior fornix or laparoscopy.

Insufficient information of palpation data in acute purulent inflammation is not significantly supplemented by ultrasound examination.

Echographic signs of acute purulent salpingitis are "enlarged, thickened, elongated fallopian tubes, characterized by a decrease in echogenicity, every second patient in the rectum-uterine cavity is noted accumulation of free fluid."

It is believed that transvaginal echography provides better detail in assessing changes in patients with salpingo-oophoritis, revealing "abnormalities" that were not seen in transabdominal echography, in 71% of cases.

However, unlike the formed inflammatory formations, with purulent salpingitis, echoscopic signs are not always informative, since with the initial signs of inflammation, slightly changed tubes are not always clearly visualized, and one has to focus more on the clinical picture and the results of puncture.

A highly informative therapeutic and diagnostic procedure for uncomplicated forms of purulent inflammation, especially purulent salpingitis, is a puncture of the posterior vaginal fornix. This method of diagnosis allows you to get purulent exudate for microbiological examination and exclude another urgent situation, for example, ectopic pregnancy, ovarian apoplexy.

Currently, it is generally accepted that laparoscopy has the most pronounced diagnostic value, which is why it is the "gold standard" for diagnosing and treating patients with uncomplicated forms of purulent inflammation.

With laparoscopy, the clinical diagnosis of acute salpingitis was confirmed in 78.6% of cases, while the polymicrobial etiology of purulent inflammation was identified.

There are two factors limiting the application of the method: high cost and the risk associated with the procedure. The method, of course, is shown when examining patients who are in a state of shock, in the absence of a history of sexual contact or uncertainty in the diagnosis.

Differential diagnosis of purulent salpingitis

First of all, acute salpingitis should be differentiated with acute appendicitis. For acute appendicitis, the relationship of the disease with the previously provoking, genital and extragenital risk factors for the development of inflammatory processes of internal genital organs is not characteristic; the disease occurs suddenly.

An early sign of acute appendicitis is paroxysmal pain, initially localized in the navel, more often above it (in epigastrium). Somewhat later the pain is concentrated in the area of the cecum. Unlike acute inflammation of the appendages, the pains do not irradiate anywhere, but intensify with coughing. There is nausea and vomiting, often repeated, although the absence of the latter does not exclude the presence of acute appendicitis. The stool and the exhaust of gases are usually delayed. Diarrhea is rare. Multiple stools (10-15 times), especially with tenesmus, for acute appendicitis is not typical.

Body temperature rises to 37.8-38.7 ° C. As with any other acute disease of the abdominal cavity, three criteria are of great importance: the state of the pulse, the tongue and the abdomen. With acute appendicitis, the pulse in the first day stably increases to 90-100 beats / min, the tongue is at first clothed and moist, but soon becomes dry. Naturally, the study of the stomach is crucial. The place of greatest soreness depends to a certain extent on the location of the appendage. In most patients, a slight tapping on the abdominal wall helps to locate the site of pain localization. The feeling of the belly is best done not with fingertips or even fingers, but with a "flat hand", because it is logical to look for a painful area, not a painful point, without clearly defined boundaries. In acute appendicitis, the symptoms of Sitkovsky (strengthening of pain in the right iliac region with the patient on the left side) and rovsing (the pain in the cecal region with jerking in the left ileal region) are crucial. Sharp soreness is usually combined with protective muscle tension in a limited area. In the initial stages, the Shchetkin-Blumberg symptom appears in the right ileal region, and as the process spreads, it is found on the left, and also in the upper abdomen.

With gynecologic pelvioperitonitis, there are also symptoms of irritation of the peritoneum and protective tension of the abdominal muscles, however, local symptoms are less pronounced.

Laboratory data are not specific for acute appendicitis, as they reflect the presence of a pathological focus and the intensity of inflammation. However, in the study of blood, in contrast to purulent salpingitis, with acute appendicitis there is an hourly increase in the number of leukocytes, leukocytosis can reach 9-12 thousand.

Practitioners often have to make a differential diagnosis between acute salpingitis and ectopic pregnancy, especially in the case of formation of clotted hematomas and their suppuration, when the secondary secondary inflammatory changes mask the original disease.

The distinctive features of ectopic pregnancy are the following symptoms:

• in almost all patients there are violations of the menstrual cycle - more often delay in menstruation, followed by a long bloody discharge of smearing character; In this case, dubious and likely signs of pregnancy may appear in patients;
• pain has a characteristic irradiation in the rectum;
• often a periodic short-term impairment of consciousness (dizziness, fainting, etc.), erroneously associated, as a rule, with possible uterine pregnancy or household factors;
• in patients with ectopic pregnancy there are no clinical and laboratory signs of acute inflammation, and practically all of them have symptoms of chronic salpingo-oophoritis.

Differential diagnosis is assisted by the determination of chorionic gonadotropin in the blood and urine (in the laboratory or by rapid tests), and in a number of women, the use of echoscopy (visualization of a deciduously transformed endometrium or fetal egg outside the uterus). In case of doubt, a puncture of the posterior vaginal fornix or laparoscopy is recommended.

Rarely, acute purulent salpingitis must be differentiated with acute cholecystitis.

In 1930, Fitz-Hag-Curtis first described a series of observations of patients who had undergone laparotomy for acute cholecystitis (later, all had a diagnosis of gonococcal perihepatitis). Now it is known that chlamydia can also cause such damage. J. Henry-Suchet (1984) considers perihepatitis to be one of the characteristic signs of acute gonorrhea and chlamydial salpingitis. In this case, gynecological patients are often mistakenly diagnosed with cholecystitis and are treated with it.

[1], [2], [3], [4], [5]