An Unusual Presentation of a Ruptured Huge Ovarian Cyst with Torsion: A Case Report

Return to Issue Full text - PDF Full text - HTM Full text - EPUB Listen to the Audio highlight the text below to listen. Greener Journal of Medical Sciences Vol. 14(2), pp. 131-135, 2024 ISSN: 2276-7797 Copyright ©2024, the copyright of this article is retained by the author(s) https://gjournals.org/GJMS Article's title & authors An Unusual Presentation of a Ruptured Huge Ovarian Cyst with Torsion: A Case Report. Mba Alphaeus G1, Biibaloo Legborsi Livinus2, Ntishor Gabriel Udam3 Department of Obstetrics and Gynaecology, Rivers State University Teaching Hospital. Department of Ear, Nose and Throat, Rivers State University Teaching Hospital. 3. Community and Clinical Research Division, First-On-Call Initiative, Port Harcourt. ARTICLE INFO ABSTRACT Article No.: 093024119 Type: Case Report Full Text: PDF, PHP, HTML, EPUB Background: Ruptured ovarian cyst is a gynaecological emergency. Mortality from this pathology can be averted based on a high index of suspicion and timely intervention. Aim: To present this uncommon clinical entity and offer management modality. Case Report: Mrs KP 28-year-old Para 0+0 who presented with complaints of severe abdominal pain of a day’s duration. There was associated history of abdominal swelling of about one year duration. On examination at presentation, she was in severe painful distress, marked pale, dehydrated, but conscious, her pulse rate was 114 beats per minute, and her blood pressure was 90/40mmHg. The abdomen was distended with generalised tenderness, and difficulty was observed in ascertaining abdominal organs due to tenderness. Pelvic examination revealed difficulty performing a bimanual examination due to tenderness, a full pouch of Douglas and positive cervical motion tenderness. A diagnosis of ruptured ectopic pregnancy to rule out an ovarian cyst accident was entertained. The packed cell volume was 34%, the serum pregnancy test was negative. An abdominopelvic ultrasound scan revealed there was a huge solid mass with unclear exact origin. The dimensions of the mass were 14.70cm by 10.10cm, with irregular borders and a heterogeneous echotexture with severe cystic degeneration. She was counselled on her condition, and informed consent was obtained. She subsequently had an exploratory laparotomy. Findings was a huge right ruptured ovarian cyst that measured 14cm by 30cm and weighed 5kg. She had right ovariectomy, blood loss with haemoperitonium was 1.7 litres. She received two units of whole blood intra-operatively and was managed with antibiotics and discharged home on the 5th post operative day in stable clinical state. The histology report showed mature cystic teratoma with rupture. On follow-up visit, she was counselled on the histology report and her concerns of future fertility. Conclusion: We have presented this rare clinical entity matured ruptured cystic teratoma. Though in this scenario was ruptured, however prompt diagnosis and treatment offers better prognosis. Accepted: 30/09/2024 Published: 11/10/2024 *Corresponding Author Dr Mba A MBBS, FWACS E-mail: mbagogo1@ gmail. com Keywords: Ovarian cyst tortion, Ruptured ovarian cyst, Mature cystic teratoma INTRODUCTION An ovarian cyst is a fluid-filled sac within the ovary. Most cases of ovarian cysts are asymptomatic. Severe symptoms might result if the cyst ruptures, bleeds, or becomes infected or torted and presents with vague symptoms like vomiting, severe lower abdominal pain, dizziness, fever, or fainting.1 Ovarian cysts are common in the reproductive age group aged 18-45 years and rare in premenstrual and postmenopausal age groups.2 A hemorrhagic ovarian cyst is a functioning cyst that arises when a cyst bleeds. Abdominal discomfort on one side of the body is a symptom of this cyst.1 Haemorrhagic cysts are commonly detected by grey-scale ultrasound but are often misdiagnosed due to their variable sonographic appearance, mimicking other organic adnexal masses. Most haemorrhagic ovarian cysts are functional, and though a handful of them can be neoplastic, they are universally benign.5 Though ovarian cyst torsions are rare gynaecological emergencies, they usually present diagnostic challenges. The varied imaging features and nonspecific symptoms of ovarian torsion can lead to a delay in identification, with misdiagnosis being common. It refers to a complete or partial rotation of the adnexal supporting organ, resulting in ischemic changes in the ovary.4 Mature cystic teratomas (MCT) of the ovary or dermoid cysts are commonly encountered benign ovarian lesions accounting for approximately 70% of benign tumours and originating from germ cells.5 Surgical intervention may be indicated in cases of large cysts greater than 5 cm in diameter, severe persistent abdominal pain, failure of the cyst to resolve spontaneously, masses that cannot be confirmed to be benign by ultrasound criteria and finally, the occurrence of complications such as rupture and ovarian torsion.6 CASE PRESENTATION A 28-year-old nulliparous businesswoman with a secondary level of education. She presented to a private facility with complaints of severe abdominal pain of 24 hours duration before presentation to the facility. The pain was of sudden onset, temporarily relieved by ingestion of analgesics, she graded the pain to be eight on a scale of 0 to 10. At the onset of pain, she presented to a pharmacy where some unknown medications were administered, including parenteral medicines. There was associated weakness and dizziness but no fainting spells, and with worsening symptoms, she presented to the facility for proper medical attention. Her menstrual history was not significant. She had noticed abdominal swelling of about one year duration, with swelling described as painless and the size of an orange in the lower abdomen. The swelling had gradually increased, with no associated fever, vomiting, change in bowel habits, or urinary symptoms. On examination at presentation, she was in severe painful distress, marked pale, dehydrated, but conscious, her pulse rate was 114 beats per minute, and her blood pressure was 90/40mmHg. The abdomen was distended with generalised tenderness, and difficulty was observed in ascertaining abdominal organs due to tenderness. Pelvic examination revealed normal vulva and vagina, difficulty performing a bimanual examination due to tenderness, a full pouch of Douglas and positive cervical motion tenderness. A diagnosis of ruptured ectopic pregnancy to rule out an ovarian cyst accident was entertained. The packed cell volume was 34%, the serum pregnancy test was negative, and HIV 1 &2 were seronegative. An abdominopelvic ultrasound scan revealed normal abdominal findings with pelvic organs that showed a normal-sized uterus with a subserous myoma nodule that measured 4.4 by 3.5 cm. There was a huge solid mass with unclear exact origin. However, the location appeared more towards the right adnexum, extending to the upper abdominal region and was suggestive of an ovarian tumour. The dimensions of the mass were 14.70cm by 10.10cm, with irregular borders and a heterogeneous echotexture with severe cystic degeneration. There were also a few areas of vascularity on the colour doppler. In addition, there was associated marked irritation of the bowel loops, especially at the right ileac region, with associated inflammatory changes suggesting acute appendicitis. The left ovary harboured a similar mass of size 3.6cm by 3.3cm with predominantly hyperechoic echotecture. Furthermore, there was also marked intraperitoneal fluid, which contained lots of debris but no bowel dilatation. She was counselled on her condition, and informed consent was obtained. She subsequently had an exploratory laparotomy. Findings were haemoperitonium of about 1.5 litres, a huge right ruptured ovarian cyst that measured 14cm by 30cm and weighed 5kg. She had right ovariectomy, blood loss with haemoperitonium was 1.7 litres. She received two units of whole blood intra-operatively and was managed with antibiotics and discharged home on the 5th post operative day in stable clinical state. The histology report showed mature cystic teratoma with rupture. On follow-up visit, she was counselled on the surgery, the histology and her concerns of future fertility. Figure 1 Figure 2 Figure 3 DISCUSSION: Ovarian cyst torsion is a rotation of the ovarian vasculature, entirely or partially. It occurs due to ovarian twisting over the infundibulopelvic and utero-ovarian ligamentous support, obstructing blood flow.7 It commonly occurs between the third and fourth decade of a woman’s life, though it can happen at any age.8 Our patient was 28 years of age, falling in this age bracket. Common symptoms include progressively worsening abdominal pain of sudden onset with varying characteristics and may be intermittent if the ovary is torting and detorting.9 Nausea and vomiting are also common symptoms.10 Fever may be a pointer of ongoing ovarian necrosis, while abnormal vaginal discharge may occur if a tubo-ovarian abscess is torted. As seen in our patient, rupture of ovarian cyst is generally either spontaneous or associated with torsion (figures 2&3). Very rarely, however, rupture may be a consequence of blunt abdominal trauma11. Most ovarian cysts happen on the right, usually due to more extensive utero-ovarian ligaments on that side. The sigmoid colon on the left also reduces the anatomical space in that region, leading to a higher incidence of right-sided lateralisation.12 A right-sided mass was seen on ultrasound and intra-operatively in our case. However, Pramana et al. reported a left-sided torsion in a 19-year-old3, while Baradwan et al. reported a case of a 20-year-old with bilateral ovarian torsion.13 This variability, however, affects the course of medical and surgical intervention as the latter case was managed by performing a left-sided salpingo-oophorectomy and right cystectomy. The main risk factor for torsion and rupture is the presence of an ovarian mass greater than or equal to 5cm in diameter. This large diameter increases the chances of rotation on the axis of its supporting ligaments, leading to reduced venous drainage and, ultimately, arterial supply9. Pregnancy and vomiting are independent risk factors for ovarian torsion. Other risk factors include history of abdominal surgeries, tubal ligation and pathologies like dermoid cysts, which cause ovarian enlargement.3, 13 Our patient had a massive ovarian mass with dimensions of 14.70cm by 10.10cm that extended to the upper abdomen, which is a major risk factor for the condition. The diagnosis of ovarian cyst torsion is difficult due to the generalised nature of presenting complaints that are usually associated with a range of medical conditions, including ectopic pregnancy, appendicitis, pelvic inflammatory disease, and tubo-ovarian abscess. A transvaginal Doppler ultrasound scan (TVDUS] is the imaging modality of choice in ovarian torsion, however, ruptures can be seen on pelvic scans.14 TVDUS usually have high sensitivity, but this depends on many factors, including the operator’s skill and the patient’s anatomy. The most sensitive ultrasound findings documented in studies are ovarian oedema, abnormal ovarian blood flow, relative ovarian enlargement, and free fluid or the whirlpool sign, which results from the twisting of the vascular pedicle.9 There should be a high index of suspicion of ovarian cyst torsion and rupture due to functional impairment and long-term complications without prompt and adequate intervention. An ovarian torsion with rupture is a gynaecological emergency that requires urgent surgical intervention. The desire for future fertility, the viability of the ovary, and the patient’s clinical condition influence the choice of treatment. In women of reproductive age, ovarian salvage should be the first management line. However, necrotic ovaries beyond damage are often removed.9 A salpingo-oophorectomy is also indicated in post-menopausal women and visualisation of malignant cysts. Laparoscopy is the first line of treatment, but open laparotomy is indicated in settings without resources for laparoscopy.15 The ovaries are visualised for viability before the decision of salvage or removal is made. Over 90% of ovaries were seen to be viable following ovarian detorsion.16 For our patient, we did an exploratory laparotomy with right ovariectomy on account of the ruptured huge ovarian cyst. The primary complication of ovarian torsion is the failure to salvage the ovary, which often necessitates a salpingo-oophorectomy and affects fertility. Other complications with bleeding and rupture include infection, usually following necrosis, peritonitis, sepsis, adhesions, ovarian atrophy, and chronic pain.17 Follow-up care is critical following ovarian detorsion to monitor for potential sequelae and ensure good recovery. Regular follow-up appointments also ensure early detection of issues related to fertility, particularly if one or both ovaries were affected or a salpingo-oophorectomy was done. Counselling is necessary, especially with loss of ovarian function. Overall, ongoing follow-up care supports the patient's recovery and addresses long-term concerns. REFERENCES Anul Gavankar, Jaya Galvai. Hemorrhagic ovarian cyst: A case report. International Journal of Research and Report in Gynaecology, 2022; 5(1): 120-24. Pallavi PS, Navyatha B, Divya SP. Study of Benigh Ovarian Cyst and Adnexal Torsion in Tertiary Hospital. International Journal of Pharmacy and Pharmaceutical Research, 2016; 6(4): 400-412. Pramana C, Monica I, Rizkik O, Dewanti I, No author N author, Andriani D, et al. Ovarian Cyst Torsion: a Case Report. International Journal of Medical Reviews and Case Reports. 2020;(0):1. Tsapralis D, Prodromidou A, Vasiliadis G, Vergadis C, Machairas N, Syllaios A, Misiakos E, Schizas D. Rupture of Mature Cystic Teratoma in a Young girl caused by a car accident: an extremely rare case and review of literature. Folia Med (Plovdiv). 2021; 63 (3): 438-442. doi:10.3897/folmed.63.e55388. PMID:34196155. Ahmed M. Abbas, Marian T. Amiu Sara M. Tolba, Mohamed K. Ali. Hemorrhagic Ovarian Cysts: Clinical and Sonographic Correlation with the Management Options. Middle East Fertility Society Journal. 2016; 21:41-45. Balan P. Ultrasonography, Computed tomography and Magnetic resonance Imaging in the assessment of pelvic Pathology. Eur J Radiol 2006; 58:148-55. Wells, L. K. (2016). Recognition of Ovarian Torsion: A Case Report. Proceedings of UCLA Healthcare, 20. https://doi.org/10.1016/s0015-0282(03)00123-7 Wikipedia Contributors. Ovarian torsion . Wikipedia. Wikimedia Foundation; 2019 . Available from: https://en.wikipedia.org/wiki/Ovarian_torsion Guile SL, Mathai JK. Ovarian Torsion . PubMed. Treasure Island (FL): StatPearls Publishing; 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560675/ Schwartz BI, Huppert JS, Chen C, Huang B, Reed JL. Creation of a Composite Score to Predict Adnexal Torsion in Children and Adolescents. J Pediatr Adolesc Gynecol. 2018 Apr;31(2):132-137. Avital Yohann, Constance W. Lee, Saleem Islam. Traumatic rupture of an ovarian teratoma e Case report and review of the literature. Journal of Pediatric Surgery Case Reports .2017; 23: 34-36 Lucchetti, M. C., Orazi, C., Lais, A., Capitanucci, M. L., Caione, P., & Bakhsh, H. (2017). Asynchronous Bilateral Ovarian Torsion: Three Cases, Three Lessons. Case reports in pediatrics, 2017. https://doi.org/10.1155/2017/6145467 Baradwan, S., Sendy, W., & Sendy, S. (2018). Bilateral dermoid ovarian torsion in a young woman: a case report. Journal of medical case reports, 12(1), 159. https://doi.org/10.1186/s13256-018-1698-8 Ovarian torsion - Symptoms, diagnosis and treatment | BMJ Best Practice US . bestpractice.bmj.com. Available from: https://bestpractice.bmj.com/topics/en-us/792 Winton C, Yamoah K. Ovarian torsion and laparoscopy in the paediatric and adolescent population. BMJ Case Rep. 2020 May 12;13(5):e232610. doi: 10.1136/bcr-2019-232610. PMID: 32404320; PMCID: PMC7228144. Psilopatis I, Damaskos C, Garmpis N, Vrettou K, Garmpi A, Antoniou EA, Chionis A, Nikolettos K, Kontzoglou K, Dimitroulis D. Ovarian Torsion in Polycystic Ovary Syndrome: A Potential Threat? Biomedicines. 2023 Sep 10;11(9):2503. doi: 10.3390/biomedicines11092503. PMID: 37760944; PMCID: PMC10526011. Schraga ED. Ovarian (Adnexal) Torsion: Practice Essentials, Pathophysiology, Etiology . Medscape.com. Medscape; 2022 . Available from: https://emedicine.medscape.com/article/2026938-overview?&icdlogin_success_email_match_fpf Cite this Article: Mba, AG; Biibaloo, LL; Ntishor, GU (2024). An Unusual Presentation of a Ruptured Huge Ovarian Cyst with Torsion: A Case Report. Greener Journal of Medical Sciences, 14(2): 131-135. PDF VIEWER