Gynecologic Pathology as it Relates to General Surgery Lily Shamsnia, MD Department of Obstetrics...

Gynecologic Pathology as it Relates to General Surgery

Lily Shamsnia, MDDepartment of Obstetrics and Gynecology

Tulane University School of Medicine

GYN vs. General Surgery

• Many Gynecologic disorders mimic those of General Surgery, especially regarding etiology of acute and chronic pelvic pain, as well as the diagnosis/treatment of an acute abdomen.

• Abdominal pain may be infectious, inflammatory, anatomic or neoplastic

Acute right lower abdominal pain in women of reproductive age: Clinical clues Hatipoglu, et. al

Patient (n=290), n (%) Age (yr)

Acute appendicitis 224 (77.2) 21 (12-24)

Perforated appendicitis 29 (10) 22 (14-42)

Ovarian cyst rupture 21 (7.2) 24 (15-38)

Corpus hemorrhagic cyst rupture 12 (4.2) 21 (13-55)

Adnexal Torsion 4 (1.4) 24 (19-30)

290 female patients presenting to ED with acute abdominal pain

Alvarado ScoreAlvarado Score Point Value

Abdominal pain migrating to RLQ 1

Anorexia or urine ketone 1

Nausea or vomiting 1

Tenderness in RLQ 2

Rebound tenderness 1

Fever 1

Leukocytosis 2

Neutrophilia 1

Scoring: 0-4: unlikely appendicitis 5-6: consistent with dx of appendicitis 7-8: probable appendicitis 9-10: very probable appendicitis

Symptoms/signs of appendicitis similar to many GYN disorders

Approach to Acute Abdominal/Pelvic pain in a Female

• History and physical exam• Bimanual and speculum exam• UPT/ serum bHCG• Cervical cultures • Radiologic studies

DDx pelvic pain of GYN origin

• Pelvic Inflammatory Disease (PID)• Tubo-ovarian Abscess (TOA)• Endometriosis• Ruptured or Hemorrhagic Ovarian Cyst• Adnexal Torsion• Uterine Fibroids• Ectopic Pregnancy

Pelvic Inflammatory Disease (PID)

• Inflammation and infection of the upper female genital tract, including the cervix, fallopian tubes, and uterus.

• Peritonitis also may be present. • Early diagnosis and treatment to prevent long-

term morbidity is key. • An episode of PID can cause recurrent/chronic

PID, chronic pelvic pain, ectopic pregnancy, infertility.

PID

• Ascending infection from the lower genital tract. – Neisseria gonorrhoeae, – Chlamydia trachomatics, – Diptheroids, – Gardenella vaginalis, – Mycoplasma genitalium, – Bacteroides, – Anaerobes, – Streptococci

• > 50% cases have more than one organism isolated

PID

• Symptoms/signs mimic that of appendicitis due peritoneal irritation and can often be vague/ misleading

• Diagnosis missed in up to 35% of patients. • Mucopurulant cervical/vaginal discharge is

present with PID

PID- CDC Diagnostic Criteria• Minimal Dx Criteria-

– Pelvic or lower abdominal pain AND – CMT OR uterine tenderness OR adnexal tenderness

• Additional criteria:– oral temperature >101 F– Cervical/vaginal mucopurulent discharge– WBC on microscopy of vaginal secretions– Elevated ESR– Elevated CSR– Documented gonorrhea/chlamydia cervical infection

• Most specific– Endometrial biopsy showing endometritis – Radiographic imaging showing thickened fluid filled tubes indicative of

infection– Laparoscopic abnormalities consistent with PID

PID

• Ultrasound– Transvaginal preferable – Uterine enlargement/thickened endometrium – Ovarian enlargement (reactive inflammation)– Edematous distended fallopian tubes with

hypervascularity on Doppler US• CT scan– Pelvic inflammation and fat stranding, indistinct

tissue planes.

PID- Ultrasound

Ovary

Dilated fallopian tube

PID- CT scan

Right side , normalLeft side, thickened/inflamed tubal wall

PID- treatment

• Outpatient: Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO BID x 14 days +/- Metronidazole 500 mg PO BID x 14 days

• Inpatient: – A: Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg PO/IV

q 12 hours– B: Ampicillin/Sulbactam 3 g IV q 6 hours PLUS Doxycycline

100 mg PO/IV q 12 hours • Diagnostic laparoscopy vs exploratory laparotomy- If

diagnosis is unclear ( i.e. PID vs appendicitis vs TOA), or no improvement with antibiotics

PID on laparoscopy

Fitz High Curtis

• Occurs with pelvic inflammation of PID spreads to right upper quadrant via right paracolic gutter and involves peritoneal surface of liver.

• Violin-string adhesions, typically encountered during laparoscopy, typically laparoscopic cholecystectomy

Fitz High Curtis

Tubo-Ovarian Abscess (TOA)

• 35% of women with PID, 20-40 years old, small percentage postmenopausal.

• 2/3 are unilateral- may lead to misdiagnosis of appendicitis if on right side.

• Initial insult to the female genital tract- inoculation and destruction of fallopian tube epithelium a purulent exudate with low oxygen environment favorable for anaerobic organisms.

• Inflammatory response induces edema, ischemia, and necrosis of fallopian tube.

TOA

• Surrounding structures may become involved in the expanding inflammation and walled off abscess, including ovary, round ligament, broad ligament, contralateral fallopian tube and ovary, appendix, bowel, and bladder.

• With expansion, rupture of TOA can occur. • TOAs can be the result of non- gynecologic

disease, including diverticulitis, appendicitis, inflammatory bowel disease, and surgery.

TOA• Polymicrobial:

– E. coli, – Bacteroides– Peptostreptococcus– Enterococcus– Klebsiella– Staphylococcus– Streptococcus– H. influenza.

• N. gonorrhoeae and C. trachomatis are rarely cultured from TOAs.• Anaerobic bacteria are present in 60-100% of TOA cultures.

TOA

• Lower abdominal pain (acute vs chronic), nausea/vomiting

• +/- fevers/chills- up to 50% of patients are afebrile • If bowel is involved- anorexia/diarrhea • Leukocytosis- present but not reliable indicator • Palpable abdominal/pelvic mass, rebound

tenderness/guarding• CMT, mucopurulent discharge, vaginal

discharge/abnormal bleeding

TOA- Imaging

• Ultrasound- sensitivity > 90% for diagnosis. – Transabdominal- larger field of view for identifying adnexal

masses.– Transvaginal- detailed view of pelvic anatomy and

vasculatyure. • Appear complex, multilocular, cystic with thickened

walls and internal echoes/debris. • Tubal and ovarian architecture disordered with

destruction of planes between the ovary and developing abscess.

• Cogwheel sign- thickening of endosalpingeal folds.

TOA- Imaging

• CT scanning if diagnosis is unclear- septated tubular structure with thickened walls.

• Hydronephrosis/hydroureter may be seen when surrounding tissue is involved with the inflammation.

• Gas bubbles within the fluid collection- highly specific for TOA

• TOA vs. appendicitis- TOA was highly associated with appearance of abnormal ovary, peri-ovarian fat stranding, small bowel and recto-sigmoid thickening, and free fluid in the pelvis.

TOA on US

TOA on CT

Appendicitis on US

Appendicitis- CT Imaging

TOA- Treatment

• Treat infection and preserve fertility• Mainstay of therapy is antibiotics +/-

additional drainage procedures ( image guided transabdominal or transvaginal approach)

• Parenteral antibiotics until 48 hours afebrile; continuation of oral antibiotics for 14 days

TOA- Surgical Treatment

• 1) Concern for alternative surgical emergency i.e. appendicitis, cholecystitis, bowel obstruction/perforation

• 2) Failure of clinical response after 48-72 hours of medical therapy

• 3) Intra-abdominal rupture of TOA- emergent surgery warranted due to hemodynamic instability, sepsis, multi-system organ failure

TOA on laparoscopy

Endometriosis

• Defined as presence of endometrial glands and stroma outside uterine cavity.

• Most accepted theory- development is retrograde menstruation. Other theories include coelemic metaplasia of endometrial tissue with lymphatic spread, and transformation of embryonic rests.

Endometriosis

• Prevalence - 7-10% in general population; up to 50% in infertile women

• 60% of women with dysmenorrhea, 87% of women with CPP

• Symptoms- dysmenorrhea, dyspareunia, CPP, pain with ovulation, micturition, defection

• Risks- early menarche, short menstrual cycles, reduced parity, heavy bleeding

• Increased risk- tall /thin women, excess alcohol and caffeine

Endometriosis

• Most common location of endometrial implants is the ovaries, followed by deep/central pelvis and vesico-uterine pouch

• 60% of Stage IV disease involves intestinal tract (rectum, sigmoid, colon, appendix, small bowel)

• With Stage IV disease- pain mediated by deep infiltrating endometrial lesions in muscular propria of surrounding organs

Endometriosis Treatment

• 1st line- NSAIDs and hormonal therapy • If pain is refractory, surgical intervention is

warranted, with laparoscopic ablation or removal (preferred) of endometrial implants

• With significant bowel/bladder involvement, laparotomy may be required

Endometriosis

• MRI- superior for detection of endometriomas- hyperintense signal of T1 weighted imaging or hypodense signal of T2 imaging

• CT- endometrioma appears as cystic mass with hyderdense clot within

• US- used to assess endometrioma involving ovary- hypoechoic cystic structure

Endometrioma on MRI

Endometrioma on US

Endometriosis on laparoscopy

Catamenial pneumothorax

• Recurrent pneumothorax occurring within 72 hours of onset of menses.

• SOB, CP, cough; usually RIGHT sided • Manifestation of thoracic endometriosis, likely

via transdiaphragmatic lymphatic/vascular transplantation of endometrial tissue

• Confirmed by presence of endometrial glands and stroma within pleura or diaphragm

Ruptured/Hemorrhagic Ovarian Cysts

• Most common- functional cysts, including corpus luteal cysts/ follicular cysts, which are more prone to rupture due to increased vascularity as part of the menstrual cycle

• Rupture typically occurs between 20-26 days of menstrual cycle (i.e. luteal phase, after ovulation has occurred)

Ruptured/Hemorrhagic Ovarian Cysts

• Mittelschmerz- sensation of pain and release of peritoneal fluid associated with physiologic rupture of corpus luteum, cyst during ovulation

• Ruptured cyst- most commonly right sided• Usual symptoms- acute pain, vaginal bleeding,

nausea/vomiting, shoulder tenderness• If associated with massive hemorrhage- signs of

circulatory collapse

Ruptured/Hemorrhagic Ovarian Cysts

• Ultrasound- thin wall, anechoic; with hemorrhage and clotting of blood- internal echoes appear with fluid and debris

• With massive hemorrhage- free intraperitoneal fluid present, while cyst itself is collapsed

Hemorrhagic Ovarian Cysts

Ruptured/Hemorrhagic Ovarian Cysts

• Hemodynamically stable- conservative management, analgesia, observation

• Unstable- emergent surgical intervention, even if diagnosis is uncertain

• If active/uncontrollable bleeding present- oophorectomy recommended; otherwise, conservative management with preservation of ovary is preferred

Ovarian Torsion

• Partial/complete twisting of adnexa around its vascular pedicle ( infundibulopelvic ligament and tubo-ovarian ligament)

• Vascular and lymphatic obstruction results, leading arterial occlusion and ovarian necrosis

• Right adnexa most commonly involved, possibly due to longer utero-ovarian ligament on the right vs. decreased mobility of left adnexa due to presence of sigmoid colon

Ovarian Torsion

• Commonly associated with ovarian mass (cyst, neoplasm, etc) as a fixed point around which adnexa may twist

• Previous pelvic surgery also increases risk, likely due to post surgical adhesions around which adnexa can twist

• Patients with ovarian hyperstimulation syndrome (due to assisted reproductive technology) also at increased risk

Ovarian Torsion

• Acute pelvic/abdominal pain; prolonged pain associated with high risk of necrosis

• Nausea, vomiting, dysuria, urinary retention, frequency, urgency

• Low grade leukocytosis/fever less common • Peritoneal signs

Ovarian Torsion

• Ultrasound- gold standard • Enlarged ovary (>5 cm) with edema• Absent arterial/venous flow is highly specific

for torsion • Pelvic free fluid present with

infarction/hemorrhage

Ovarian Torsion

No Doppler Flow

Ovarian Torsion

“Whirlpool sign”

Ovarian Torsion

• Preferred surgical treatment- laparoscopic detorsion with salvage of adnexa

• Oophorectomy warranted if ovary appears necrotic, ovarian mass present, or there is evidence of peritonitis

• If ovary is salvageable, consider ovarian suspension to decrease likelihood of recurrence.

Ovarian Torsion

Ovarian Torsion

Ovarian Torsion in Pregnancy

• Adnexal torsion is the most common complication of an adnexal mass occurring during pregnancy, typically in 1st and 2nd trimesters

• If ovarian mass without torsion is noted, surgery is performed in 2nd trimester

• If torsion is present, surgery is warranted regardless of gestational age

Uterine Fibroids

• Most common pelvic tumor in women; consist of hormonally responsive smooth muscle cells, which can lead to progression during pregnancy or with hormonal contraceptive use, and typically regress after menopause

• Most common symptoms- abnormal vaginal bleeding, pelvic pain and pressure

• Hydronephrosis can occur with chronic impingement of ureter

Uterine Fibroids

Degenerating fibroids that have outgrown/lost blood supply can present as acute abdominal pain

Ultrasound- anechoic, irregular cystic spaces within the fibroid, indicating necrosis

Ectopic PregnancyDefined as any pregnancy outside uterine cavity, most commonly in the fallopian tube (ampulla> isthmus> fimbria), abdominal cavity, ovary, cervix, or uterine cornua

Typically occur between 6-10 weeks gestation, and is the leading cause of death during the 1st and 2nd trimesters of pregnancy

Ectopic Pregnancy

• Risk factors- previous ectopic pregnancy, history of PID, previous pelvic surgery, smoking, infertility, intrauterine device use

• Symptoms- pelvic pain, vaginal bleeding • Quantitative bHCG- initial test– if >1500 mIU/mL, pregnancy can be seen on

transvaginal US– If > 5000 mIU/mL, pregnancy can be seen on

abdominal US

Ectopic Pregnancy

• US evaluation- 1st evaluate if pregnancy is intrauterine; at 5 weeks gestation (corresponding to bHCG between 1000-2000 mIU/mL) a gestational sac should be visible

Ectopic Pregnancy

• With ectopic pregnancy- gestational sac/fetal pole +/- cardiac activity seen outside the uterine cavity

• Adnexal mass separate from ovary with empty uterus, free fluid in pelvis, tubal “donut” sign and “ring of fire” on Doppler ultrasound

Ectopic Pregnancy on US

Ectopic Pregnancy- “Ring of Fire”

Ectopic Pregnancy

• If unruptured and hemodynamically stable- can consider conservative management with medical therapy i.e. Methotrexate with follow up of serial bHCG levels at day 4 and day 7 after injection, and then weekly until negative

• If bHCG fails to decrease by 15% from day 4 to day 7 after MTX injection, consider additional MTX injection vs. surgery

Ectopic Pregnancy

• If ruptured, emergent surgery is indicated, especially if hemodynamically unstable

• Depending on degree of patient stability, surgical approach via laparoscopy (preferred) versus laparotomy, with salpingostomy versus salpingectomy

• Salpingectomy indicated with uncontrolled bleeding, severely damaged fallopian tube, large gestational sac (> 5 cm)

Ectopic Pregnancy

Appendicitis in Pregnancy• 1/800 - 1/1500 pregnancies, incidence slightly

higher in the second trimester • Appendiceal rupture occurs more frequently

in pregnant women, especially in the third trimester -possibly due to inconclusive symptoms/reluctance to operate on pregnant women delaying diagnosis and treatment; associated with higher risk of fetal loss (36% vs. 1.5%)

Appendicitis in Pregnancy

• Less likely classic presentation, especially in late pregnancy– More GI complaints– Leukocytosis is common with pregnancy

• Pain typically originates at McBurney's point regardless of the stage of pregnancy; however, location of the appendix migrates a few centimeters cephalad with the enlarging uterus

• In the third trimester, pain may localize to the mid or even the upper right side of the abdomen

Appendicitis in Pregnancy

• US- wide variation in the diagnostic performance during pregnancy; gravid uterus can interfere with visualizing the appendix and performing graded compression (particularly in the third trimester)

• CT imaging- when clinical findings and ultrasound examination are inconclusive and MRI is not available

Appendectomy in Pregnancy

• Open preferred if late gestation• Laparoscopic – slight left lateral positioning if 2nd trimester and

beyond– avoid cervical instrumentation– open entry techniques/ trocar placement under

direct visualization– limit intra-abdominal pressure to less than 12

mmHg

Cholelithiasis in Pregnancy

• Gallstones are more common during pregnancy- decreased gallbladder motility/increased cholesterol saturation of bile– Estrogen increases cholesterol secretion– Progesterone reduces bile acid secretion and slows

gallbladder emptying, promoting the formation of stones via biliary stasis

• In pregnant women with biliary colic, supportive care will lead to resolution of symptoms in most cases, but the symptoms frequently recur later in pregnancy

Cholelithiasis in Pregnancy

• 1st episode - supportive care vs. cholecystectomy (laparoscopic if in 1st/2nd trimesters)– low risk of fetal mortality and high risk of disease

relapse/need for urgent surgery later in pregnancy. • Acute cholecystitis cholecystectomy – If near term- conservative management is

preferable as surgery is technically difficult, with plan for cholecystectomy 6 weeks postpartum

The End!Questions?