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Auto-amputated ovarian cyst with tubal and ileal compression sequels

Bilal Mirza, Lubna Ijaz, Muhammad Sharif, Muhammad Afzal Sipra, Muhammad Saleem, Afzal Sheikh
Department of Pediatric Surgery, The Children’s Hospital and The Institute of Child Health Lahore, Pakistan

 

Correspondence

Bilal Mirza
Department of Pediatric Surgery
The Children’s Hospital and The Institute of Child Health Lahore, Pakistan
Tel :+923454772583
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract
Ovarian cysts contribute a major share of cystic lesions diagnosed in antenatal life. Quite often, these cysts are benign and resolve spontaneously. Some times these cysts got twisted, resulting in ovarian loss. We report a case of a patient, presented with acute intestinal obstruction. At operation, an auto-amputated ovarian cyst and ipsilateral tubal atresia were noted, as incidental findings, in addition to the ileal stenosis. We appraised that auto-amputated ovarian cyst caused the tubal and ileal compression sequels.

Key words: ovarian cyst, intestine, fallopian tube, atresia

 

Introduction

Majority of cystic lesions in the female fetuses, identified on antenatal ultrasonography, are ovarian cysts. Most of fetal ovarian cysts are follicular and luteal. These cysts are, most of the times, benign and tend to resolve spontaneously in intrauterine life and even few months after the birth [1].

The complications may arise usually in bigger cysts (more than 4cm). The most sinister complication is the ovarian loss due to the ovarian torsion, auto-amputation, and cyst hemorrhage [2].

Other complications are hydronephrosis, intestinal obstruction, polyhydromnios etc [3, 5].

Fallopian tubal atresia is a very rare entity and only few cases have been reported in the literature. It is usually associated with other urogenital anomalies especially transverse vaginal septum [6, 7].

We report a case of auto-amputated ovarian cyst in a patient withof intestinal obstruction. The cyst was causing compression sequels on ileum and fallopian tube.

Case presentation

A 28-day old female baby was presented to the surgical emergency department of our institution with complaints of abdominal distension, bilious vomiting, constipation and reluctance to feed for 3 days. Patient belonged to some remote area where antenatal facilities were not properly available. Few of her antenatal scans during the early pregnancy were available, giving nil information about the existence of any cystic lesion in the fetus.

On history taking, the mother told that, at birth, the weight of the baby was 2.4 kg; she was a term baby and a product of spontaneous vaginal delivery at home in a village setting. The newborn tolerated feeds during the first week of life., After 7 days when she started vomiting out the feeds; some times non bilious and some times yellowish in color. Initially the frequency of vomiting was restricted to 2-3 times a day; but in the third week, it increased to 4-5 times a day. They visited some local practitioner who administered the baby with intravenous antibiotics; but the vomiting did not settle down. Three days before presenting to us, the patient developed abdominal distension, bilious vomiting after every feed, and constipation. At the time of presentation in our institution, her weight was 2.8kg. On clinical examination, her temperature was normal, pulse 105/ min, and respiratory rate 30/min. Abdomen was distended with visible gut loops on inspection. On palpation no mass lesion was present. The bowel sounds were absent and digital rectal examination revealed empty rectum. Provisional diagnosis of mechanical intestinal obstruction was made and patient was investigated. Patient was initially resuscitated with intravenous fluids. Naso-gastric tube was passed and antibiotics started.

Abdominal X-ray showed multiple air fluid levels. Ultrasound showed massive gaseous distension of the intestinal loops which obscuredand other viscera were obscured by massive gut gases. Her hemoglobin was 13g/dl with normal serum electrolytes, blood sugar, clotting profile, and blood urea and serum creatinine. The patient was prepared for surgery and an exploratory laparotomy was performed for dealing the acute intestinal obstruction. Following were the operative findings noted during the laparotomy:

1. There was a stenosed portion of midileum causing distension of proximal intestinal loops (fig. 1).

2. In the left hemi abdomen, a dark brown colored cyst was present having a grayish nodular thickening on one side (fig. 2, 3). The cyst was freely floating in the peritoneal cavity and not attached to the surrounding structures.

3. Left sided ovary was absent. Left sided fimbrial end of fallopian tube was freely floating in the abdomen. Some fibers of connective tissue were present between the fimbrial end and the uterine end of the fallopian tube and the portion in between was absent (fig. 4). Right sided ovary and fallopian tube were present normally.

7.1.17

Figure 1: Ileal stenosis: the proximal small bowel is

distended and distal ileum is collapsed

7.1.16

Figure 2: Auto-amputated ovarian cyst inside the abdomen

 

 

7.1.19 7.1.18

Figure 3: Auto-amputated ovarian cyst outside the abdomen.

Figure 4: Absence of a portion of fallopian tube between two black spots. Notice the distance between uterine end and ampullary end of fallopian tube on either side

Resection and ileo-ileal end to end anastomosis was performed for ileal stenosis. Cyst was eviscerated and sent for histopathology which revealed a benign ovarian cyst and hemorrhagic fluid inside.

Post operative recovery was uneventful. Nasogastric tube was removed on 3rd post operative day, and started orally feeds on 4th post operative day. Patient was discharged on 6th post operative day. Patient was on follow up for 6 months and then never returned after that time.

Discussion

Ovarian cysts are classified on the basis of ultrasound findings, as simple cysts and complex cysts. In simple cysts the ultrasound reveals a cyst having well defined walls and is echo free. In complex cysts the features are debris fluid levels, septa or retracting clot within the cyst [2]. In the index case, the antenatal and post natal ultrasound abdomen were not helpful to delineate or even appreciate any cystic lesion in the abdominal cavity. This might be due to the lack of expertise, as in case of antenatal scans which were performed in the village setting and where no body cared for the qualification of the radisonologist; and due to the difficulty in delineating other viscera in presence of massive gaseous shadows that might preclude the sonologist for identifying other abnormality on scan.

The exact etiology of ovarian cyst development in intrauterine life is not known, however it is believed the raised levels of chorionic gonadotrophins play a role. The usual course of the cyst is spontaneous resolution in intrauterine life or up to 6 months after birth due to decrease in maternal hormonal stimulation [3, 4].

The management of ovarian cysts depends upon various factors as, size, type and anticipated complications. Cysts with size less than 4 cm are usually managed by weight and see policy and merely serial ultrasound scans check the parameters. These cysts resolve spontaneously in intrauterine life or few months after the baby born [3].

Bigger cysts, more than 4 cm, are prone to get complications of torsion, hemorrhage and pressure sequels. To prevent such dreadful complications, some surgeons tried ultrasound guided antenatal aspiration of the cysts. This reduces the size of the cysts and the chances of ovarian loss, however multiple aspirations were needed and an expert radiologist was the prerequisite who could distinguish between cysts of other origins [1]. A few authors suggested antenatal ultrasound guided puncture of the cyst to reduce the morbidity.

If the cyst torsion, auto-amputation or suspicion of cyst rupture or hemorrhage becomes evident, surgical intervention becomes necessary [3]. Previously, open surgical removal of cyst was performed but, now a days, due to the recent advances in therapeutic and diagnostic modalities, laparoscopic management is most striking and successful [9].

Ovarian cyst can cause compression effects on surrounding structures. Polyhydromnios, hydronephrosis, intestinal obstruction and perforation were reported in the literature [10]. In our case the cyst had compression effects on the intestine and the fallopian tube.

Zampieri et al. reported a case of antenatal torsion and ipsilateral complete tubal atresia in 2008. In their case, they proposed the combined tubo-ovarian torsion as a causative factor for their findings [8].

Our case is unique because the patient presented with signs of intestinal obstruction and the cyst was an incidental finding. One mechanism that can explain the ipsilateral tubal atresia is combined tubo-ovarian torsion., But the question is, why only the central part of fallopian tube was atretic. The other most plausible explanation for both the ileal stenosis and ipsilateral tubal atresia, is long term compression effects of the auto-amputated ovarian cyst on the ileum and fallopian tube.

Due to compression effect, the ileum became stenotic. This caused initially partial intestinal obstruction and finally, complete intestinal obstruction. Similarly, the continuoused compression on the fallopian tube caused the loss of segment of fallopian tube as described earlier.

To conclude, antenatal diagnosis and close surveillance is necessary to prevent the ovarian loss as happened in our case. Ovarian cyst can cause multiple impairment s to the patient for example: ovarian loss, intestinal obstruction and major surgeryoperation.

 

 

References

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