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Abstract / Introduction Discussion Conclusions

References

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Abstract; - Acute ischaemic bowel disease is a life threatening vascular emergency with 1/1000 admission and high mortality rate of 50-90% depending on the extent and site of damage, especially in elderly patients. We report a case of a 77 year old woman in otherwise good health who presented with a massive ovarian cyst which resulted in ischaemia of the small bowel. Introduction; Acute ischaemic bowel disease is a life threatening vascular emergency with 1/1000 admission and high mortality rate of 50-90% depending on the extent and site of damage, especially in elderly patients. Benign ovarian cyst causing extensive small bowel ischaemia is very rare and vigilance from the clinician is needed to ensure early diagnosis and management.

Images: a) Transabdominal scan of the pelvis, b) CT scan of the abdomen.

Acute ischaemic bowel disease is a life threatening vascular emergency with 1/1000 admission and high mortality rate of 50-90% depending on the extent and site of damage, especially in elderly patients. With the advent of modern CT scan it is now easier to diagnose ischaemic bowel injury at an earlier stage if clinical suspicion is raised.It is very unusual to have a massive ovarian cyst persisting for several days to cause obstruction and bowel ischaemia, but the clinician has to keep in mind about its remote possibility and the outcome.

Case Report

Case Report;We report a case of a 77 year old woman who presents to the A/E with a 3 weeks history of back pain, abdominal pain and distension. She reports associated loss of appetite, reduced mobility but no weight loss. Patient deteriorated quickly on admission via A/E with EWS (early warning score) up to 6. She developed severe metabolic acidosis and multidisciplinary care was sought with the involvement of Critical care specialist, anaesthetist, gynaecologist and Surgeons to stabilise patient prior to surgery. An urgent CT scan was arranged which shows large cyst within the abdomen extending from the pelvis all the way up to the upper abdomen. This was displacing and compressing the bowel and solid organs. ( see images) Patient subsequently underwent laparotomy and removal of the massive right ovarian cyst. Extensive small bowel gangrene was noted 5cm from the duodeno-jejunal flexure to the ileo-caecal valve with the typical distribution of superior mesenteric artery thrombosis or embolism. This was thought to be inoperable and incompatible with life. Patient died about 9hours later with the cause of death been septic shock, extensive small bowel gangrene and very large ovarian cyst. Post mortem examination was not performed and results of ovarian cyst histology confirmed a benign right ovarian serous cystadenoma

With the increase in average life expectancy, acute bowel ischemia represents one of the most threatening abdominal conditions in elderly patients (1–7). Acute bowel ischemia may involve the small or large bowel, be segmental or diffuse, and be only partial mural (meaning that it involves only the mucosa and submucosa, with or without parts of the muscularis) or transmural (meaning that it leads to continuous necrosis of all bowel wall layers [i.e., infarction]). Ischemic colitis, as an example of only partial mural and superficial colonic ischemia, is the most common type of colitis in patients older than 50 years and is often self-limiting, whereas acute bowel infarction (accounting for approximately 1% of all cases of acute abdomen) has a higher annual mortality rate than colon cancer (1,3). Acute occlusions of the mesenteric arteries may be related to numerous other conditions, however, including atherosclerosis, thromboembolism from the aorta, mesenteric arterial thrombosis, aortic or mesenteric arterial dissection, spontaneous or postoperative cholesterol embolization, aortic surgery, stent placement, or therapeutic embolization of mesenteric vessels to treat gastrointestinal haemorrhage (8-11).Occlusions of the mesenteric arteries may also be caused by antiphospholipid antibody syndrome and especially by various types of vasculitis and thrombotic microangiopathies.Occlusions of mesenteric veins may be primary or secondary and may be found proximally or distally. Mesenteric venous thrombosis may be caused by infiltrative, neoplastic, or inflammatory conditions (which, in rare instances, may encase mesenteric veins) or by various types of abdominal infection—with or without thrombophlebitis (12, 13). Furthermore, thrombotic mesenteric venous occlusions may occur in patients with a hypercoagulability state.

In our case there was a huge simple cystadenoma of the ovary associated with extensive bowel gangrene along the distribution of superior mesenteric vessel. This was not detected by CT scan. Only one case has been reported to date which shows an ovarian teratoma presenting as small bowel obstruction in elderly woman (16). In our case whether the massive ovarian cyst caused huge pressure or mass effect to cause acute bowel obstruction and ischaemia or due to mass effect there was thrombosis or clot formation in mesenteric vessels leading to extensive bowel ischaemia is a matter of open discussion. A coincidental finding with the on- going bowel ischaemia and bowel gangrene and huge ovarian cyst is difficult to explain as this patient was otherwise fit and healthy without any other co morbidity other than hypertension which was controlled on medications.

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Benign Ovarian Cyst- Is it as simple as we think?-A Case Report Ajayi. S, Datta. T, Chetan. U. Blackpool Teaching Hospital, Blackpool. UK.