With abdominal pain and a CT showing a 3.5 cm intramural uterine fibroid, physiologic cul‑de‑sac fluid, and a stable small fat‑containing umbilical hernia but no acute intra‑abdominal abnormality, what is the likely etiology and appropriate management?

Likely Etiology and Management of Abdominal Pain with Uterine Fibroid and Umbilical Hernia

The abdominal pain is most likely unrelated to the incidental 3.5 cm intramural fibroid or stable umbilical hernia, and requires clinical reassessment for functional gastrointestinal disorders, gynecologic causes, or early inflammatory processes not yet evident on CT. 1

Interpretation of CT Findings

The CT demonstrates no acute intra-abdominal pathology requiring urgent intervention 1:

• Intramural fibroid (3.5 cm): This is an incidental finding. Intramural fibroids of this size rarely cause acute abdominal pain unless undergoing degeneration (which would show characteristic imaging features like heterogeneous enhancement or hemorrhage) 2, 3
• Trace physiologic fluid: Cul-de-sac fluid in small amounts is normal in women of reproductive age and does not indicate pathology 1
• Stable umbilical hernia: A small, fat-containing umbilical hernia that is stable and contains only fat (not bowel) is not a source of acute pain unless there are signs of incarceration or strangulation, which would be evident on CT 3, 4, 5

Clinical Reassessment Strategy

Since CT with contrast is the gold standard for evaluating nonlocalized abdominal pain with 92.2% diagnostic certainty and changes diagnosis in 49-54% of cases, a negative study significantly reduces likelihood of acute surgical pathology 1:

Immediate evaluation should focus on:

• Gynecologic causes: Perform pelvic examination to assess for cervicitis, pelvic inflammatory disease, endometriosis, or ovarian pathology not visible on CT. The endocervical fluid noted could indicate cervicitis if symptomatic 6
• Functional disorders: Consider irritable bowel syndrome, functional dyspepsia, or visceral hypersensitivity, which are common causes of abdominal pain with negative imaging 1
• Early inflammatory processes: CT has a negative predictive value of only 64% for upper abdominal pathology and commonly misses early pancreaticobiliary inflammation, gastritis, and duodenitis 7

When to Consider Additional Imaging

Repeat or alternative imaging is warranted only if 7:

• Pain persists or worsens over 12-24 hours with new clinical findings
• Development of fever, leukocytosis, or peritoneal signs
• Elevated or rising inflammatory markers (amylase, lipase, CRP)

If additional imaging is needed 7:

• MRI abdomen/pelvis without and with contrast: Demonstrates 99% accuracy for detecting bowel inflammation, pancreaticobiliary disease, and gynecologic pathology missed on CT 7
• Pelvic ultrasound with transvaginal approach: Superior to CT for evaluating endometrial pathology, small ovarian lesions, and adenomyosis that could explain pain 6

Management of Incidental Findings

The uterine fibroid requires no acute intervention 2:

• Intramural fibroids of 3.5 cm are typically asymptomatic
• Symptoms from fibroids (heavy bleeding, bulk symptoms) develop gradually, not acutely
• Surgical intervention is reserved for symptomatic fibroids causing menorrhagia, pressure symptoms, or infertility 2

The umbilical hernia requires no urgent repair 3, 4, 5:

• Fat-containing hernias without bowel incarceration are managed electively
• The rare case reports of fibroids herniating through umbilical defects occur during pregnancy with massive uterine enlargement, not applicable here 3, 4, 5, 8
• Elective repair can be considered if the hernia becomes symptomatic or enlarges

Common Pitfalls to Avoid

• Do not attribute acute pain to chronic incidental findings: A 3.5 cm intramural fibroid and stable umbilical hernia are unlikely pain sources 2, 3
• Do not repeat CT immediately: Diagnostic yield drops to 5.9% on repeat imaging without interval clinical change, exposing patients to unnecessary radiation 1, 7
• Do not overlook extra-abdominal causes: Consider urinary tract infection, musculoskeletal pain, or referred pain from thoracic pathology 7
• Recognize CT limitations: Standard CT misses early mucosal disease, small pancreatic inflammation, and functional disorders 7

Recommended Clinical Pathway

For persistent unexplained pain after negative CT 7:

1. Serial clinical examination over 12-24 hours
2. Repeat laboratory markers (CBC, CRP, amylase, lipase)
3. Consider gynecologic consultation for pelvic examination
4. If pain resolves: outpatient follow-up with primary care or gynecology
5. If pain persists with normal repeat labs: consider functional disorder and trial of empiric therapy
6. If new clinical findings develop: MRI abdomen/pelvis or targeted ultrasound based on symptoms 7