Dig Dis Sci (2007) 52:1749–1751 DOI 10.1007/s10620-006-9237-7
R E V I E W PAP E R
Masters Allen Syndrome: A Review Rahul Gupta · Ehab Elakkary · Mostafa Sadek · Yash Lakra
Received: 11 November 2005 / Accepted: 30 January 2006 / Published online: 6 April 2007 C Springer Science+Business Media, Inc. 2007
Keywords Appendicitis . Master Allen syndrome . Broad ligament . Peritonitis . Abdominal pain
Literature review Allen and Masters in their classic 1955 article [1] defined traumatic laceration of uterine support as a syndrome characterized by laceration in the posterior leaf of broad ligament along with abnormally mobile cervix designated as the universal joint 1. Since their original description, a number of authors have defined and redefined this entity to look for a plausible explanation of the symptoms that include dyspareunia and acute or chronic pelvic pain. Because of the rare occurrence of this disease and its limited reporting in the literature, it is important to recognize this as a distinct entity that must be included in the differential diagnosis of pelvic pain. Twenty-five patients with chronic pelvic pain were studied by De Brux et al. [2]; the classic tear of broad ligament was found in 17 of the patients. Similarly, Lawry [3] presented a series of 23 patients; presenting complaints included dyspareunia, excessive fatigue, general pelvic pain, and backache. None of the patients presented acutely with R. Gupta Department of General Surgery, Providence hospital, Southfield, Michigan, USA E. Elakkary () · Y. Lakra Department of Surgery, North Oakland Medical Centers, 461 W. Huron, Pontiac, MI 48341, USA e-mail:
[email protected] M. Sadek Department of Obstetrics and Gynecology, Ministry of Health, Cairo, Egypt
signs of peritoneal inflammation. All patients gave history of pregnancy. Traumatic laceration has been reported during intercourse, resulting in severe pelvic pain. Lewis reported a case of Master Allen syndrome that presented with a picture of acute lower abdominal pain for which the patient was explored in the operating room [4], where a loop of bowel was identified strangulating through the defect, requiring resection. In our endeavor to widen the thought process of diagnosing the condition behind a lower right quadrant abdominal pain in women, we present this unusual case of a woman who presented with features of acute peritoneal inflammation in the right lower quadrant and was explored as a case of appendicitis. Eventually, Allen and Masters syndrome was diagnosed. Allen and Masters never defined this entity in the context of acute right lower quadrant pain nor have any of the other authors who have written extensively on the subject documented this unique presentation of the condition. This happens to be a rare presentation of this unique syndrome. Clinical case presentation A 28-year-old Caucasian woman G6P1 presented to the emergency department with abdominal pain of 2 days’ duration. The patient described the pain as severe, sharp with no radiation, and localized in the right lower quadrant with no specific exacerbating or relieving factors. The patient experienced nausea and mild anorexia, but no vomiting or change in bowel habits. Past medical history was significant for gastroesophageal reflux disease and hypothyroidism. Past surgical history was significant for cervical cerclage. Last menstrual period was 1 week before admission. The patient was afebrile with stable vital signs. Her weight was 180 lbs, height was 5 6 , and body mass index was 29. Significant
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Fig. 1 Bilateral congestion of the infundibulopelvic ligaments
Fig. 3 Left infundibulopelvic ligament showing less congestion
physical examination findings included a nondistended abdomen with right lower quadrant direct and rebound tenderness associated with involuntary muscular guarding and positive obturator sign. The pelvic examination showed no signs of pelvic inflammatory disease as cervical motion tenderness or vaginal discharge. Rectal examination was within normal limits with negative hemoccult test. The patient’s workup included complete blood count, which showed elevated white blood cell count of 11.4 K/Ul, and a negative pregnancy test. Abdominal x-rays showed a nonspecific gas pattern. The patient was assessed to have a classic picture of acute appendicitis and was taken to the operating room for laparoscopic appendectomy. Hasson trocar was introduced through a supraumbilical incision and pneumoperitoneum was achieved. Another 5mm suprapubic midline port and left lower quadrant 5-mm port were placed under direct vision. The patient was placed in Trendelenburg position with right side up to facilitate exposure of the appendix. The cecum was identified and the teniae coli were followed caudally to the base of the ap-
pendix. A blunt grasper was used to hold the base of the appendix, which was found to be grossly normal; however, we decided to remove it to avoid future diagnostic confusion (pathologic microscopic examination showed atretic vermiform appendix with no inflammation). A bullet dissector was used to create a window in the base of the mesoappendix. A multifire endoscopic stapler with a 3.5-mm cartridge was used to staple across and divide the appendix at the base. The same instrument, with a 2.5-mm cartridge, was used to divide the mesoappendix. Hemostasis was achieved and the specimen was removed using an Endocatch bag. Diagnostic laparoscopy revealed bilateral pelvic congestion (Fig. 1) more on the right side (Fig. 2) than the left (Fig. 3). Intraoperative gynecology consult was obtained and the patient was assessed with bilateral congestion of the infundibulopelvic ligament with a tear in the right posterior broad ligament (Fig. 4). Examination of the tubes and ovaries showed no abnormalities. The pelvis was irrigated and the abdomen was deflated. The incisions were closed in layers. The
Fig. 2 Severe congestion in the right infundibulopelvic ligament
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Fig. 4 Normal right ovary and a tear in the right posterior broad ligament
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postoperative course of the patient went uneventful. The patient denied pain after the surgery. Diet was advanced as tolerated and she was discharged home on postoperative day 2 in good condition and has been doing well since. This case of Master Allen syndrome was different in its presentation; there was no history of trauma. Similarly, the patient did not present chronically with complaints of dyspareunia or pelvic pain, which were considered as an essential part of the syndrome complex. The patient presented acutely and with signs of peritoneal irritation with leukocytosis. Diagnostic laparoscopy did not reveal any other cause of this presentation. Conclusion The syndrome of bilateral laceration was described by Allen and Masters in 1955 [1]. The symptomatology associated with this condition has been dyspareunia and chronic pelvic pain. However, signs of acute peritoneal inflammation may
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occur and may cause diagnostic confusion. Therefore, this condition, although not common, may be kept as a differential diagnosis in female patients with right lower quadrant peritoneal inflammatory signs without an obvious etiology during surgical exploration.
References 1. Allen WM, Masters WH (1955) Traumatic laceration of uterine support; the clinical syndrome and the operative treatment. Am J Obstet Gynecol 70:500–513 2. De Brux JA, Bret JA, Demay C, Bardiaux M (1968) Recurring pelvic peritonitis. A comment on the Allen-Masters syndrome. Am J Obstet Gynecol 102:501–505 3. Lawry EV (1968) Traumatic laceration of uterine supports. Further observations of the Allen-Masters syndrome. Am J Obstet Gynecol 101:315–321 4. Lewis MI (1969) Small-bowel obstruction secondary to traumatic lacerations of the uterine supports. (The Allen-Masters syndrome). Dis Colon Rectum 12:253–255
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