Case Report - (2021) Volume 7, Issue 9
Ikhatua EP*, Agarwal S and Kumar G
Wrexham Maelor Hospital, Betsi Cadwaladr University Health Board, North Wales, UK
Received Date: August 26, 2021; Accepted Date: September 17, 2021;; Published Date:September 24, 2021
Citation: Ikhatua EP, Agarwal S, Kumar G (2021) Not All Pelvic Masses in Women Are of Gynaecological Origin. Gynecol Obstet Case Rep Vol.7 No.9:156
Acute diverticulitis is considered to be due to perforation of a diverticulum. Abdominal pain is the most common complaint. Patients may have localized peritoneal signs or generalized peritonitis resulting from rupture of a diverticular abscess. Differentials include cystitis, nephrolithiasis, IBS, acute appendicitis, infectious colitis, ischemic colitis, colorectal cancer and gynaecological conditions. We report an unusual presentation of a pelvic mass which was thought to be of ovarian origin, prompting a referral to gynaecology. She was referred from primary care to gynaecology as suspected ovarian malignancy. She presented with history of left lower abdominal pain, diarrhoea, vomiting, loss of appetite and feeling unwell. There was a firm, immobile mass in the left lower abdomen. CT abdomen+pelvis showed a large multi-locular abscess measuring 11.6 cm × 7.3 cm × 8.0 cm, probably arising from perforated sigmoid colon with diverticular disease. Percutaneous drainage of the abscess was performed. She also had a course of antibiotics. She was discharged 3 days after the intervention. Complicated diverticulitis manifests as bowel obstruction, abscess, fistula, or perforation. Gynaecological differentials include tubo-ovarian abscess, ovarian cyst accident, ectopic pregnancy.
Pelvic masses; Suspected ovarian malignancy; Abdominal pain
A diverticulum is a sac-like protrusion of the colonic wall. Acute diverticulitis is inflammation, generally considered to be due to perforation of a diverticulum. Abdominal pain is the most common complaint in patients with acute diverticulitis. The pain is usually in the LLQ due to involvement of the sigmoid colon. Nausea and vomiting occur due to bowel obstruction or ileus due to peritoneal irritation. Patients may have a low-grade fever. A tender mass may be palpable due to peri-colonic inflammation or a diverticular abscess. Patients may have localized peritoneal signs with localized guarding, rigidity, and rebound tenderness. Perforation with generalized peritonitis may result from rupture of a diverticular abscess into the peritoneal cavity or free rupture of an inflamed diverticulum with fecal contamination of the peritoneum [1,2]. Suspect acute diverticulitis in a patient with lower abdominal pain and abdominal tenderness. The pain is usually in the LLQ in Western populations but may be suprapubic or in the RLQ, particularly in patients with right-sided diverticulitis. Elevated CRP (>50 mg/dL), leukocytosis can support the diagnosis. Differential diagnosis: cystitis, nephrolithiasis, IBS, acute appendicitis, infectious colitis, ischaemic colitis, colorectal cancer and gynaecological conditions [3-5].
We report an unusual presentation of a pelvic mass which was thought to be of ovarian origin, prompting a referral to gynaecology out-patient clinic rather than emergency referral for immediate assessment. This was diagnosed as pelvic abscess resulting from perforated bowel [6]. This illustrates the need to think of bowel as a potential cause of pelvic mass in females and the need for urgent referral, admission and investigations for timely management.
A 56-year-old nulliparous female was referred on fast-track pathway from primary care to gynaecology out-patients as “suspected ovarian malignancy”. She presented with 3 week history of griping left lower abdominal pain, shooting down the left thigh, diarrhoea, vomiting, loss of appetite and feeling unwell. Previous surgery, chemotherapy and radiotherapy for breast cancer were noted.
A firm, immobile palpable mass was noted in the left lower abdomen, approx. 20 weeks size and confirmed on vaginal examination. Cervix noted to be very short (previous loop biopsy for CIN 3) with some watery bloodstained discharge on the vulva (vulval hidradenitis). Planned for: Emergency admission for pain relief, fast-track CT scan of abdomen/pelvis +/- Ultrasound scan, urgent bloods including CA125, Intravenous fluids and antiemetics. Investigations revealed:
Elevated inflammatory markers
WBC = 18.1 × 109/L
CRP = 248 mg/L
Hyponatraemia Na=129 mmol/L
Normal CA125=16 μ/L
CT Abdomen + Pelvis showed slightly hydronephrotic left kidney with hydroureter down to the pelvic brim with a large multilocular abscess measuring 11.6 cm × 7.3 cm × 8.0 cm probably arising from perforated sigmoid colon with diverticular disease and extending into the iliac muscle and psoas. Associated Deep Venous Thrombosis noted within the left external iliac and common femoral vein (Figure 1).
Figure 1: Pelvic collection before drainage.
Percutaneous drainage of the abscess was performed by interventional radiologist using the Seldinger technique with ultrasound confirmed complex left iliac fossa collection. A 12 French locking pigtail catheter inserted into Left Iliac Fossa abscess. Frank thick pus was drained and sent for culture and sensitivity. The drain was left in-situ.
Anticoagulation withheld until after drainage for the coexisting DVT. She was commenced on intravenous tazocin and metronidazole for 3 days after which the antibiotics were converted to oral co-amoxiclav based on sensitivity result, for a total duration of 14 days. She was discharged home 3 days after the intervention with a plan to have the drain reviewed by the colorectal nurse practitioner (Figure 2).
Figure 2: Pelvic collection after drainage.
A repeat CT abdomen+pelvis two weeks after showed that the large left pelvic collection had almost completely resolved, with a small residual collection measuring 12 mm in the left iliac fossa.
Complicated diverticulitis manifests as bowel obstruction, abscess, fistula, or perforation. Suspect acute diverticulitis in a patient with lower abdominal pain and abdominal tenderness, usually in the left lower quadrant. Gynaecological differentials include tubo-ovarian abscess, ovarian cyst accident, ectopic pregnancy. A high index of suspicion for non-gynaecological causes in such situations enables appropriate investigations and subsequent management to ensure a good outcome as in this case.
