Transcript Cecile Graves yo Female MR# 1533488

Pt. suffered from chronic intermittent abdominal
pain for the last 3-4 months. Over the 24 hours prior to
coming into the ER her pain is greatly worsened in
severity. The pain radiates to her back and is
accompanied by nausea and bloating. She has not had
a bowel movement in three days, but has had flatus.
She is afebrile. Pt. has a history of a partial bowel
resection in 2004 for rectal prolapse. Abdomen is
diffusely tender on physical exam. Her labs are
negative, including HCG and CEA.
Upright AXR
Supine AXR
AXR shows bowel loops being displaced out of pelvis by a circular shaped 19
cm mass with soft tissue density. It appears to be distinct from the bladder wall.
Axial Abdominal CT
CT shows a large pelvic mass that
appears to be arising from the right
adnexa. Multilocular cyst with one primary
cyst and some septations.
Transabdominal
Ultrasound
US shows well-defined borders
around hypoechoic space with
acoustic enhancement posteriorly.
There are septations and a mural
nodule in the posterior wall. Mural
does not show blood flow on
Doppler but septations do. DePriest
score of 8.
Adnexal Mass Differential
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Cystadenoma (serous or mucinous) or cystadenocarcinoma
Hemorrhagic cyst (fenestrated without solid component)
Endometrioma (diffuse low level echoes)
Ectopic pregnancy
Teratoma (contains calcium and/or fat)
Abscess (air-fluid level)
Hematoma
Functional cyst (follicular, corpus luteum, or theca lutein)
Malignant lesions are more likely to have irregularities within the wall,
thick septations, papillary projections, solid components, ascites, and
size >9 cm. Blood flow within septations is a good marker of neoplasm,
either benign or malignant.
DePriest score can be used to determine likelihood of malignancy. Its
scoring system is based upon cystic wall structure, septation structure,
and tumor volume. A score of 5 confers a higher likelihood of
malignancy.
Hospital Course
Pelvic mass was not appreciated on AXR overnight, but was seen the
following morning. A CT had already been order at the point due to the
patient’s continued pain. The housestaff was notified of the mass, and the US
was order for better characterization. A review of her February 2005 CT
showed no mass at that time. She was admitted to the GYN service. She was
taken to the OR after several days for exploratory laparotomy, TAH, RSO,
removal of pelvic mass, and left oophoropexy. The frozen path was consistent
with mucinous cystadenoma. She was discharged after about a week.
References
Gay, Spencer and Woodcock, Richard. Radiology Recall.
Lippincott, Williams, and Wilkins, 2000. pp. 582-584
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical
Imaging, 4th ed. Churchill, Livingston Inc., 2001. Pp. 2215-2218.
Medical Student: Nicholas Nacey SMD ‘07