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Journal of Medicine and Medical Sciences Vol. 3(4) pp. 205-207, April 2012Available online@ http://www.interesjournals.org/JMMSCopyright 2012 International Research Journals

Case Report

A case of giant ovarian cyst complicated by ascites andpelvic members vein thrombosis

1Francis Mose Dossou, Pierre-Claver Hounkp2, Josiane Angeline Tonato Bagnan3, RogerSossou4, Dansou Gaspard Gbessi1, Solange Essola1, Justin Dnakpo3, Pascal Sohou1,

Kmoko Ossni Bagnan1

1Clinique Universitaire de chirurgie viscrale (CCUV), Centre National Hospitalier Universitaire Hubert K. MAGA (CNHU-

HKM), Cotonou, Bnin.2Service polyvalent danesthsie ranimation, CNHU-HKM, Cotonou, Bnin.

3Service de maternit de lHpital de la mre et de lenfant (HOMEL), Cotonou, Bnin.

4Service de radiodiagnostic et dimagerie mdicale de lHOMEL, Cotonou, Bnin

Abstract

A 41-year old patient with a painful abdominal mass moving gradually from 4 months had been receivedat surgical consultation. Her abdomen was distended by a giant solid mass and by ascites. There was apainful and pitting edema of pelvic members and a bilateral vein thrombosis of pelvic members. A giantserous cystadenoma of the right ovary was discovered at laparotomy. A hysterectomy with bilateraladnexectomy was performed after medical treatment of the thrombosis. The postoperative course wasuneventful.

Keywords: Abdominal mass, giant ovarian cyst, venous thrombosis, ascites.

INTRODUCTION

The development of health systems and performance ofnew technologies have reduced the frequency of giantabdominal tumors by early diagnosis and treatment.However, these tumors have not entirely disappearedsince the warning signs are discrete for a long time. Inaddition, the first complaints, which appear withincreasing tumor size, are not specific and may misleadthe diagnosis, suggesting ascites (Kaya and Sakarya,2009). Thus, it increases the risk of complicationsincluding thrombotic complications (Timmermans et al.,

2009). We report a case of giant ovarian cyst complicatedby both ascites and venous thrombosis.

CASE REPORT

A 41-year-old patient, gravidity 8, parity 6, miscarriages

*Corresponding Author E-mail : dosfm@yahoo.fr

2, had been received in the service for a painfuabdominal mass moving gradually from 4 months. Shehad a known High blood pressure mistreated since 2years. There was a recent asthenia and weight loss. Onexamination, there was an impaired general condition, apainful and pitting edema of pelvic members. Theabdomen was distended and measured 111cm operimeter at its largest diameter. The umbilicus wasunfolded and there was a collateral circulation (Figure 1)The liver and spleen were not palpated and there was a

sloping dullness of the abdomen. Trans-wall puncturebrought a sero-hematic liquid. Digital rectal examinationwas normal. On vaginal examination, the cervix wasmedial and the lateral cul-de-sac of the vagina was massless. The rest of the physical examination revealedbilateral pelvic limb pain along the paths of veins.

At sonography and computed tomography (Figure 2)there was a large abdominopelvic fluid masscompressing the surrounding anatomical structures and amedium abundance ascites, but the ovarian origin of themass couldnt be stated with certainty. Doppleultrasonography revealed a deep and extent vein

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206 J. Med. Med. Sci.

Figure 1: Large abdominal mass with collateral circulation andunfolded umbilicus

Figure 3: Thrombosis of right femoral vein at Dopplerultrasound(white arrows)

thrombosis of pelvic members (Figure 3 and 4). Duringtwo weeks, the patient received anticoagulant therapybased on subcutaneous injections of Enoxaparine(Lovenox ) 12,000 IU per day in 2 doses. After twoweeks treatment and clinical amelioration,Acenocoumarol (Sintrom ) was administrated per os 8mg daily in 2 doses for two other weeks and after that,surgery was performed. There was not any repeatDoppler after anti-coagulation. At laparotomy, a large

Figure 2: CT Image of the giant ovarian cyst of the right ovary

Figure 4: Thrombosis of left femoral vein at Doppler ultrasound(white arrow)

multi-lobed mass of the right annexes was discoveredcorresponding to a giant cyst of the right ovarymeasuring 44 cm and 36 cm of diameters and weighing22 kg (Figure 5). Right adnexectomy was performed firstcompleted by total hysterectomy and left adnexectomyThe other viscera were normal. The postoperative coursewas uneventful. At pathological examination, it was abenign serous cystadenoma.

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Figure 5: poly-lobed giant ovarian cyst

DISCUSSION

Small ovarian cysts are usually asymptomatic. The firstsigns appear when the cyst volume increases. Despitepersistence of menstruations and because of associateddigestive symptoms like nausea and vomiting, theincreased volume of the abdomen simulates pregnancy..

At a later stage, the mass can reflect respiratorycompression of the diaphragm (Haspels and Zuidema,1982). Compression of the portal vein induces formationof ascites and collateral paramedian abdominalcirculation. The compression of the inferior vena cavainduces pelvic limb edema and abdominal collateralcirculation and sometimes, it also may be the cause ofthrombosis of the aorta (Timmermans et al., 2009). In ourobservation, it caused a deep and bilateral thrombosis ofpelvic members veins.

Abdominal ultrasound is the main imaging examinationin this disease. It confirms the ovarian origin of mass andprovides information on cystic nature and its wall

structure. However, ultrasound has some limitationswhen the tumor reaches large. Usually, neitherabdominal ultrasound nor CT showed any ovarianabnormality. The final diagnosis of giant ovarian cyst isconfirmed after laparotomy and histopathologicexamination of the removed specimen (Kaya andSakarya, 2009). At abdominal ultrasound, differentialdiagnosis with ascites can be made by not free floatingliver and bowel loops and no liquid in paracolic gutters(Mikos et al., 2009). Abdominal CT, ultrasound, and

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magnetic resonance imaging are noninvasive studiesable to accurately identify cystic structures. Ultrasoundappears to yield the most information for the leasexpense (Kaya and Sakarya, 2009). In the presentedcase, patient not underwent MR imaging as thisexamination doesnt exist in our country and the existing

CT equipments arent able to do coronal or sagittareconstruction.Treatment of giant cyst of the ovary is a very wide

median incision straddles the umbilicus, in order toextract, if possible, the tumor intact to avoid the risk ofdissemination in case of carcinoma, but also effusion offluid in the peritoneal cavity. Some authors advocatelaparoscopy (Dolan et al., 2006). In young womenwishing to preserve their fertility, conservative treatmenis feasible: cystectomy or oophorectomy or adnexectomywith preservation of the uterus and contra-lateral annexcould be realized. In this case, the healthy ovary will becarefully examined to avoid missing a bilateral tumorSimilarly, a sample of peritoneal fluid for cytologicaanalysis is systematic, even if the shape of the tumor isreassuring. In older or postmenopausal patients, a totahysterectomy is preferable, to prevent errors andeventual recurrences. The thrombotic risk of giant ovariancysts justifies diagnosis of thrombosis by clinicaexamination and Doppler ultrasound. A perioperativeanticoagulant therapy should be performed to prevencomplications (Timmermans et al., 2009).

CONCLUSION

The large abdomino-pelvic masses have become

curiosities in industrialized countries where the healthcare system is well developed. Conversely, they are norare in developing countries. There are no specificcharacters of the signs of the tumor at this state. Themanagement of the tumor should include correct clinicaexamination and Doppler ultrasonography to diagnosecomplications like thrombosis and prevent non favorableissues.

REFERENCES

Dolan MS, Boulanger SC, Salameh JR (2006). LaparoscopicManagement of Giant Ovarian Cyst. JSLS. 10:254-256.

Haspels AA, Zuidema PJ (1982). A giant ovarian cyst in a Javanesewoman. BMJ. 284:1410.

Kaya M, Sakarya MH (2009). Pseudoascites: Report of three casesTurk J Gastroenterol. 20(3):224-227.

Mikos T, Tabakoudis GP, Pados G, Eugenidis NP, Assimakopoulos E(2009). Failure of ultrasound to diagnose a giant ovarian cyst: a casereport. Cases Journal. 2:6909.

Timmermans J, de Booij M, Strijbos W, Teijink JA (2009). AorticThrombosis due to a giant Ovarian Cyst. EJVES Extra. 17:33-35.