Make your own free website on Tripod.com

 Home Table of Contents My Outputs Surgery Department OMMC

 Intra-abdominal Tumor
 

Up
Imperforate Anus
Osteomyelitis
Bowel Perforation
Incisional Hernia
Rectal Injury
Breast Carcinoma
Benign Prostatic Hypertrophy
Intra-abdominal Tumor

Back


Case Presentation and Discussion on Intra-abdominal Tumor

Marlou O. Padua, MD


General Data:    J.S., 13 y/o F, from Sampaloc, Manila

Chief Complaint:  Hypogastric mass

History of Present Illness:

2 mos PTA              enlarging mass on hypogastric area

                            (-) pain

                             (-) tender

                             (-) BM changes

                             (-) dysuria

                             (-) bleeding per vagina                                 

 1 mo PTA               increase in size of mass with   abdominal enlargement

 

                    consult

 Past Medical History:  unremarkable

 Family History:  unremarkable

 Personal Social History:  non-smoker, non-alcoholic beverage drinker

 Physical Examination:

Gen. Survey: conscious, coherent, ambulatory, NICRD

Vital Signs: BP:90/70              CR:84             RR:20             T:37ΊC

HEENT: pink palpebral conjunctiva, anicteric sclerae, supple neck, (-) cervical LAD

Chest/Lungs: symmetrical chest expansion,  clear breath sounds

CVS: adynamic precordium, normal rate & regular rhythm

Abdomen: globular, distended, NABS, soft, nontender, (+)  large soft mass over the entire abdomen which is nontender, movable,   (-) fluid wave

Extremeties: (-) cyanosis, (-) pallor

Rectal: no skin tags, good sphincter tone, rectal vault not collapsed, no mass, (+) feces on examining finger

 

 Salient Features:

•  13-year-old, female

•   (+) enlarging hypogastric mass

•   (-) abdominal pain

•   (-) BM changes

•   (-) dysuria

•   (-) bleeding per vagina

•   (+)  large soft mass over the entire abdomen which is nontender, movable

•   Rectal: no skin tags, good sphincter tone, rectal vault not collapsed, no mass, (+) feces on examining finger

 

Clinical Diagnosis:

Diagnosis Certainty Treatment
Ovarian cyst 70% Surgical
Mesenteric cyst 30% Surgical

 

Algorithm:

 

Do I need a para-clinical diagnostic procedure?

Yes, because I am not certain of my primary diagnosis.

 

Para-clinical Diagnostic Procedure:

  Benefit Risk Cost Availability
Ultrasound
Sensitivity 95%
Specificity 99%
nil Php 300 ✔✔✔

 

CT Scan
Sensitivity 98%
Specificity 95-97%
Radiation exposure Php 5,000 ✔v

 

 

Ultrasound Result:

Large complex mass with septations occupying almost the entire abdomen measuring 29 x 13.5 x 21 cms

The uterus is unremarkable and displaced anteriorly. No ascites seen

Diagnosis: Large complex cystic lesion, primary consideration is ovarian in origin
 

 

Pre-Treatment Diagnosis:

Diagnosis Certainty
Ovarian cyst 80%
Mesenteric cyst 20%

 

Goals of Treatment:

•  Complete removal of the mass

•  Prevent recurrence

 

Treatment Options:

  Benefit Risk Cost Availability
Complete removal of mass Recurrence
Enucleation - + Bleeding
Infection
Php 3,500
Salphingo-oophorectomy ++ - Bleeding
Infection
Php 3,500
Oophorectomy + - Bleeding
Infection
Php 3,500

 

Pre-op preparation:

•   Informed consent secured

•   Psychosocial support provided

•   Optimized patient’s physical health

•   Patient screened for any health condition

•   Operative materials secured

 

Intra-op Management:

•  Patient placed under GA

•  Asepsis and antisepsis

•  Sterile drapes placed

•   Midline infraumbilical incision done and carried done to the peritoneum

•  Intra-op findings noted

•  Incision extended superiorly

•  Ovarian mass delivered thru the incision

•  Right Oophorectomy done

•  Hemostasis

•  Correct instrument and sponge count

•  Abdomen closed by layers

•  Povidone-iodine paint

•  DSD

•  Patient tolerated the procedure well

 

Intra-operative findings:

•  Right ovary was markedly dilated with cystic consistency displacing the uterus anteriorly and the whole small bowel posteriorly to the left.

•  No signs of bowel obstruction was noted.                                 

 

Operation done: Laparotomy, Oophorectomy, R

 

Final Diagnosis: Mucinous Cystadenoma, Ovary, Right

 

Post-op Care:

•  DAT

•  Adequate hydration

•  Pain control

•  Daily wound care

 

Follow-up plan:

•  Removal of sutures after 1 week

 

Outcome:

•  Resolution of the intra-abdominal mass (ovary)

•  Live patient

•  No complications

•  Satisfied patient

•  No medico-legal suit

 

Discussion:

Ovarian Cyst

•  Ovarian cyst - sac filled with liquid or semiliquid material

•  The number of diagnoses has increased with the widespread implementation of regular PE and ultrasound technology.

•  The finding of an ovarian cyst causes considerable anxiety for women because of the fear of malignancy, but the vast majority of ovarian cysts are benign.

•  Majority of ovarian cysts - asymptomatic.

•  Even malignant ovarian cysts commonly do not cause symptoms until they reach an advanced stage

•  Pain or discomfort may occur in the lower abdomen

•  Torsion or rupture may lead to more severe pain

•  Having bowel movements may be difficult, or pressure may develop, leading to a desire to defecate

•  Micturition may occur frequently and is due to pressure on the bladder

•  Young children may present with precocious puberty and early onset of menarche


Cystadenoma

•  Frequently on a pedicle and may undergo torsion leading to pain and infarction

•  Mucinous cystadenoma – cystic tumor containing sticky, gelatinous material

•  Mucinous tumors are less likely to be malignant than the serous cystadenoma

•  20% of the serous and 5% of the mucinous tumors are bilateral

 

Mucinous Cystadenoma

•  An ovarian mucinous cystadenoma does not cause symptoms until it becomes very large.

•  Benign - allowing a conservative approach to treatment, especially in young patients who wish to maintain fertility.

•  among the largest tumors in humans.

•  as large as 149 kg (328 lb) has been reported.

•  usually occur in younger patients.

•  Unilateral – 95% of cases

•  Malignant transformation is uncommon

Mucinous Cystadenoma

•  Unusually large (15-30 cm)

•  Usually unilateral

•  Cyst filled with sticky, gelatin-like material

•  Multilocular cystic spaces

•  Benign type more common than malignant

•  Clinical: Pressure, pain, increased abdominal girth

•  US: simple or septate thin-walled multilocular cysts

 

Ultrasound

•  primary imaging tool considered to have an ovarian cyst

•  help define morphologic characteristics of ovarian cysts

•  Simple cysts

      –unilocular

      –uniformly thin wall surrounding a single cavity that contains no internal echoes

 

•  Complex cysts

      –more than one compartment (multilocular)

      –thickening of the wall

     –projections (papulations) sticking into the lumen or on the surface,

     –abnormalities within the cyst contents

 

Common Complex Masses

•  Cystadenoma (serous or mucinous)

•  Hemorrhagic

•  Endometrioma (low level echoes)

•  Ectopic Pregnancy

•  Teratoma (dermoid)

•  Abscess

•  Hydrosalpinx

 

Cystadenoma (Treatment)

•  Excision of the cyst alone, with conservation of the ovary, may be performed in patients who desire retention of their ovaries for future fertility or other reasons (endometrioma, dermoid, and functional cysts)

•  The prognosis for benign cysts is excellent

 

References:

•  Schwartz SL, et al. Principles of Surgery, 7th ed. McGraw-Hill; 1998;14: 533-97.

•  Robbins SL, Cotran RS, Kumar V, Pathologic Basis of Disease, 5th ed. WB Saunders; 1995;20:430-435.

•  Evans AT 3rd, Gaffey TA, Malkasian GD Jr, Annegers JF: Clinicopathologic review of 118 granulosa and 82 theca cell tumors. Obstet Gynecol 1980; 55(2): 231-8[Medline].

•  Farah L, Azziz R: Polycystic Ovary Syndrome. The Female Patient 1999; 24: 79-86.

•  Alqahtani A, Nguyen LT, Flageole H: 25 years' experience with lymphangiomas in children. J Pediatr Surg 1999; 34(7): 1164-8[Medline].

 •  Beahrs OH, Judd ES, Docherty MB: Chylous cysts of the abdomen. Surg Clin North Am 1950; 30: 1081-1096.

•  Bliss DP Jr, Coffin CM, Bower RJ: Mesenteric cysts in children. Surgery 1994; 115(5): 571-7[Medline].

•  Burnett WE, Rosemond GP, Bucher RM: Mesenteric cysts: Report of three cases, in one of which a calcified cyst was present. Arch Surg 1950; 60: 699-706.

•  Caruso PA, Marsh MR, Minkowitz S, Karten G: An intense clinicopathologic study of 305 teratomas of the ovary. Cancer 1971; 27(2): 343-8[Medline].

•  Clement PB: Anatomy and Histology of the Ovary. In: Kurman RJ, ed. Blaustein's Pathology of the Female Genital Tract. 4th ed. New York, NY: Springer-Verlag; 1989: 438-70.

•  Dewhurst J, Pryce-Davis J, Helm W: Diagnosis and management of granulosa/theca cell tumours in childhood. Paediatric and Adoloscent Gynaecology 1985; 3(2): 131-56.

 

Questions:

1. What is the primary imaging tool for a patient considered to have an ovarian cyst?

  1. Ultrasound

  2. Doppler of the ovary

  3. CT scan

  4. MRI

 

2. What segment of the GI tract mesenteric cyst commonly occur?

  1. Sigmoid

  2. Jejunum

  3. Ileum

  4. Transverse colon

 

Modified Multiple Choice:

          A if 1,2,3 is correct

          B if 1,3 is correct

          C if 2,4 is correct

          D if only 4 is correct

          E if all is correct

 

3. The following condition(s) appear as complex mass on ultrasonography:

  1. Cystadenoma (serous or mucinous)

  2. Endometrioma (low level echoes)

  3. Teratoma (dermoid)

  4. Abscess

 

4. The following describes mucinous cystadenoma:

  1. Unusually large (15-30 cm)

  2. Usually unilateral

  3. Cyst filled with sticky, gelatin-like material

  4. Malignant transformation is common

 

5.  The following statements are true regarding pseudomyxoma peritoneii.

  1. It is a locally infiltrating tumor composed of multiple cysts containing thick mucin

  2. Arise from ovarian mucinous cystadenomas

  3. Arise from mucoceles of the appendix

  4. Histologically they are benign

 

Answer Key:

  1. A
  2. C
  3. E
  4. A
  5. E

 

[Top of Page]      [Discussion]    [Questions]    [My Case Presentations]


 

Home ] Up ]

Send mail to marlou_padua@yahoo.com with questions or comments about this web site.
Last modified: 10/31/04