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Acute abdomen in a Jehovah’s witness with chronic anemia

      To the Editor:—Severe chronic anemia generally interferes with establishment of an accurate diagnosis in patients presenting with acute abdomen. It is particularly difficult to manage those patients, who simultaneously refuse blood transfusion. We report a female Jehovah’s Witness patient with severe anemia who was referred for an acute abdomen as a result of twisted adnexa and briefly discuss an informed consent to blood transfusion in patients below 19.
      A 19-year-old nuligravid female Jehovah’s Witness was transferred by ambulance for an acute abdomen. She was pale, sweating, and drowsy. Her blood pressure was 70/30 mm Hg, hemoglobin 5.1 g/dL, hematocrit 23.4%, and white blood cell count 9000/m3 Sonographic examination of the abdomen showed a 10 × 10 × 10-cm cystic mass in the right side of the uterus. A small amount of ascites was detected. A negative pregnancy test ruled out the presence of ectopic pregnancy. Oxygen was administered together with intravenous fluid and low-molecular weight dextran dextrose. Thirteen minutes after parentral infusion, her blood pressure returned to 90/50 mm Hg, and her conscious level improved. A preliminary diagnosis of twisted right adnexa and unexplained anemia with subsequent shock was made. Both the patient and her mother, who were Jehovah’s Witnesses, refused blood transfusion. However, her father, who was not a Jehovah’s Witness, agreed to the blood transfusion, if medically necessary. There was, thus, disagreement among the patient’s family members, but it was decided not to perform the blood transfusion even if medically necessary based on the patient’s wishes. Emergent laparotomy, which was performed under general anesthesia, revealed torsion of a right paraovarian tumor together with a right polycystic ovary. No other findings, which made the patient severely anemia, were detected in the abdominal cavity. The finding of necrotic adnexa prevented our attempt to untwist it in the young patient. Accordingly, right salpingo-oophorectomy was performed. Histopathologic examination of the removed adnexa confirmed the operative diagnosis. She has had evidence of low iron intake. In addition, postoperative investigations confirmed the absence of menorrhagic or other hematologic disease apart from iron deficiency anemia (IDA). After an uneventful recovery without blood transfusion, the patient was discharged in good condition.
      Jehovah’s Witness patients generally refuse blood transfusions even when they need surgery for acute blood loss. Surgical management of Jehovah’s Witness patients, who present with acute blood loss as a result of trauma, surgery, or other causes has been reported.
      • Collins S.L
      • Timberlake G.A
      Severe anemia in the Jehovah’s Witness case report and discussion.
      ,
      • Howell P.J
      • Bamber P.A
      Severe acute anaemia in a Jehovah’s Witness. Survival without blood transfusion.
      ,
      • Dech Z.F
      • Szaflarski N.L
      Nursing strategies to minimize blood loss associated with phlebotomy.
      However, to our knowledge, an emergent operation for a Jehovah’s Witness patient with severe IDA of long duration caused by low iron intake has not been previously reported.
      When a patient with chronic anemia is referred to a hospital with suspicion of acute blood loss, it could be difficult to identify the cause of the anemia. When the anemia is of a chronic nature, identification of the cause could be particularly difficult if the patient has been unaware of the underlying pathology. Iron deficiency arises from prolonged negative iron balance caused by a decrease in iron intake and/or blood loss. No menorrhagia or hematologic disease, apart from IDA caused by low iron intake, was present in our case preoperatively. Determination of serum iron level preoperatively would have been helpful to identify the exact nature of anemia, ie, chronic anemia or acute blood loss. Unfortunately, such tests were not performed preoperatively because of lack of menorrhagia or acute gastrointestinal blood loss. In the present case, because the patient’s conscious level improved after parentral infusion, at the age of 19, she would have been able to make her own informed consent as to whether she would consent to blood transfusion instead of her parents’ wishes. That is justified under the American and British law, but on the other hand, it is unclear under the Japanese law.
      This report also presents a rare condition of twisted paraovarian cyst together with an ipsilateral polycystic ovary. Adnexal torsion is a well-known entity and has been adequately reported. Of the entity, 14.6% include paraovarian cyst.
      • Shalev E
      • Peleg D
      Laparoscopic treatment of adnexal torsion.
      On the other hand, torsion of a polycystic ovary has also been rarely reported.
      • Sageshima M
      • Masuda H
      • Kawamura K
      • et al.
      Massive ovarian edema associated with polycystic ovary.
      However, to our knowledge, the condition, like in our case, has not been previously reported in the English literature.
      In conclusion, when a patient with unexplained severe anemia was transferred, IDA of long duration caused by low iron intake should also be considered. In addition, when a Jehovah’s Witness patient below age 19 required an emergent operation as a result of acute blood loss, because the patient’s conscious level is clear, her own informed consent for blood transfusion should be made instead of her parents wishes.

      References

        • Collins S.L
        • Timberlake G.A
        Severe anemia in the Jehovah’s Witness.
        Am J Crit Care. 1993; 2: 256-259
        • Howell P.J
        • Bamber P.A
        Severe acute anaemia in a Jehovah’s Witness. Survival without blood transfusion.
        Anaesthesia. 1987; 42: 44-48
        • Dech Z.F
        • Szaflarski N.L
        Nursing strategies to minimize blood loss associated with phlebotomy.
        AACN Clin Issue. 1996; 7: 277-287
        • Shalev E
        • Peleg D
        Laparoscopic treatment of adnexal torsion.
        Surg Gynecol Obstet. 1993; 176: 448-450
        • Sageshima M
        • Masuda H
        • Kawamura K
        • et al.
        Massive ovarian edema associated with polycystic ovary.
        Acta Pathol Jpn. 1990; 40: 73-78