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Benign Ovarian Cyst- Is it as simple as we think?-A Case Report
Ajayi. S, Datta. T, Chetan. U.
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Blackpool Teaching Hospital, Blackpool. UK.
Abstract / Introduction
Case Report
Discussion
Conclusions
Abstract; - Acute ischaemic bowel disease is a life threatening
vascular emergency with 1/1000 admission and high mortality
rate of 50-90% depending on the extent and site of damage,
especially in elderly patients. We report a case of a 77 year old
woman in otherwise good health who presented with a
massive ovarian cyst which resulted in ischaemia of the small
bowel.
Case Report;
We report a case of a 77 year old woman who presents to the A/E with
a 3 weeks history of back pain, abdominal pain and distension. She
reports associated loss of appetite, reduced mobility but no weight
loss.
With the increase in average life expectancy, acute bowel ischemia
represents one of the most threatening abdominal conditions in elderly
patients (1–7). Acute bowel ischemia may involve the small or large
bowel, be segmental or diffuse, and be only partial mural (meaning
that it involves only the mucosa and submucosa, with or without parts
of the muscularis) or transmural (meaning that it leads to continuous
necrosis of all bowel wall layers [i.e., infarction]). Ischemic colitis, as
an example of only partial mural and superficial colonic ischemia, is
the most common type of colitis in patients older than 50 years and is
often self-limiting, whereas acute bowel infarction (accounting for
approximately 1% of all cases of acute abdomen) has a higher annual
mortality rate than colon cancer (1,3).
Acute ischaemic bowel disease is a life threatening vascular
emergency with 1/1000 admission and high mortality rate of 50-90%
depending on the extent and site of damage, especially in elderly
patients. With the advent of modern CT scan it is now easier to
diagnose ischaemic bowel injury at an earlier stage if clinical suspicion
is raised.
It is very unusual to have a massive ovarian cyst persisting for several
days to cause obstruction and bowel ischaemia, but the clinician has
to keep in mind about its remote possibility and the outcome.
Introduction;
Acute ischaemic bowel disease is a life threatening vascular
emergency with 1/1000 admission and high mortality rate of
50-90% depending on the extent and site of damage,
especially in elderly patients. Benign ovarian cyst causing
extensive small bowel ischaemia is very rare and vigilance
from the clinician is needed to ensure early diagnosis and
management.
Images: a) Transabdominal scan of the pelvis,
b) CT scan of the abdomen.
Patient deteriorated quickly on admission via A/E with EWS (early
warning score) up to 6. She developed severe metabolic acidosis and
multidisciplinary care was sought with the involvement of Critical care
specialist, anaesthetist, gynaecologist and Surgeons to stabilise
patient prior to surgery.
An urgent CT scan was arranged which shows large cyst within the
abdomen extending from the pelvis all the way up to the upper
abdomen. This was displacing and compressing the bowel and solid
organs. ( see images)
Patient subsequently underwent laparotomy and removal of the
massive right ovarian cyst. Extensive small bowel gangrene was noted
5cm from the duodeno-jejunal flexure to the ileo-caecal valve with the
typical distribution of superior mesenteric artery thrombosis or
embolism. This was thought to be inoperable and incompatible with
life.
Patient died about 9hours later with the cause of death been septic
shock, extensive small bowel gangrene and very large ovarian cyst.
Post mortem examination was not performed and results of ovarian
cyst histology confirmed a benign right ovarian serous cystadenoma
Acute occlusions of the mesenteric arteries may be related to
numerous other conditions, however, including atherosclerosis,
thromboembolism from the aorta, mesenteric arterial thrombosis,
aortic or mesenteric arterial dissection, spontaneous or postoperative
cholesterol embolization, aortic surgery, stent placement, or
therapeutic embolization of mesenteric vessels to treat gastrointestinal
haemorrhage (8-11).
Occlusions of the mesenteric arteries may also be caused by
antiphospholipid antibody syndrome and especially by various types of
vasculitis and thrombotic microangiopathies.
Occlusions of mesenteric veins may be primary or secondary and may
be found proximally or distally. Mesenteric venous thrombosis may be
caused by infiltrative, neoplastic, or inflammatory conditions (which, in
rare instances, may encase mesenteric veins) or by various types of
abdominal infection—with or without thrombophlebitis (12, 13).
Furthermore, thrombotic mesenteric venous occlusions may occur in
patients with a hypercoagulability state.
In our case there was a huge simple cystadenoma of the ovary
associated with extensive bowel gangrene along the distribution of
superior mesenteric vessel. This was not detected by CT scan. Only
one case has been reported to date which shows an ovarian teratoma
presenting as small bowel obstruction in elderly woman (16). In our
case whether the massive ovarian cyst caused huge pressure or mass
effect to cause acute bowel obstruction and ischaemia or due to mass
effect there was thrombosis or clot formation in mesenteric vessels
leading to extensive bowel ischaemia is a matter of open discussion.
A coincidental finding with the on- going bowel ischaemia and bowel
gangrene and huge ovarian cyst is difficult to explain as this patient
was otherwise fit and healthy without any other co morbidity other
than hypertension which was controlled on medications.
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