Perforated bowel following hysteroscopy with myomectomy in the emergency department

Abdominal pain remains a top chief complaint for patients presenting to the emergency department (ED). Benign or emergent etiologies can present similarly. A thorough history and physical examination are critical for emergency physicians, especially for post-operative patients with concerns for a possible bowel perforation. Hysteroscopies with myomectomies are a minimally invasive surgical technique to remove fibroids. Gynecologic procedures historically have a low incidence of bowel perforation, however, in patients with post-operative pain presenting to the ED, distinguishing between a normal post-operative course and a post-operative complication can be challenging.

A 33-year-old female with a history of obesity, colitis, type II diabetes, and hypertension presented to the freestanding ED with complaints of severe lower abdominal following a hysteroscopy with myomectomy earlier that day. The initial differential diagnosis had concern for a surgical complication, although her computed tomography of the abdomen and pelvis revealed mildly dilated loops of small bowel, suggestive of a low-grade small bowel obstruction (SBO) or enteritis. On reassessment, she noted pre-operative diarrhea after taking antibiotics. After admission, a transvaginal ultrasound revealed a collection of fluid in her pelvis prompting a diagnostic laparoscopy. Two enterotomies in her ileum with two uterine defects were successfully repaired, and she recovered several days later with minimal complications.

This patient initially presented with abdominal pain associated with nausea and vomiting following a hysteroscopy with myomectomy, where initial testing led to a possible diagnosis of enteritis. Due to her continued abdominal pain, the ED physician admitted the patient, and it was found that she had two ileum perforations from suspected uterine perforations.