Ovarian Cysts and IBD

Abstract

Purpose: A 39 year old female with a history of Crohn's ileocolitis presented to the outpatient gastroenterology clinic for further evaluation of her disease. She was first diagnosed with Crohn's disease at age 16 after having symptoms for 4 years prior. At 26 years of age she underwent resection of the terminal ileum and right colon with continued multiple episodes of loose stool. After she failed to gain weight during pregnancy she underwent repeat colonoscopy and was found to have recurrent disease and underwent resection of diseased bowel with primary anastomosis at age 37. Post operative course was complicated by anastomotic leak, pelvic sepsis and enterocutaneous fistula requiring repeat surgical repair. She continues to have approximately 20 loose stools a day, poor weight gain, and severe lower abdominal pain. Only treatment at presentation was Imodium and Lortab. Physical exam did not reveal any extraintestinal manifestations of Crohn's disease. Abdominal examination was significant for multiple well-healed surgical scars, hyperactive bowel sounds but no tenderness, distention or masses. CT enterography was positive for mild active disease of the descending colon. Incidentally found on the CT scan was a large right adnexal cyst for which the patient was evaluated by gynecology. It was felt this was most likely a physiologic cyst and should be monitored prior to surgical intervention. To treat the patient's active disease she was started on Azathioprine 50 mg orally daily. Upon follow up her diarrhea had improved after 3 months of therapy and her abdominal pain was improved but was still narcotic dependent. She had also developed a perianal fistula and was started on ciprofloxacin. The patient returned 1 month later with continued improvement in her diarrheal symptoms and abdominal pain. Repeat ultrasound was done and revealed complete resolution of her ovarian cyst. Ovarian cysts occur in about 5–7% of the general population and up to 25% of women with inflammatory bowel disease. This increased incidence is most likely secondary to the up-regulation of inflammatory mediators that have an inhibitory effect on LH interfering with reabsorption of the immature follicle. Ovarian cysts are related to increased rates of pelvic and abdominal pain, and should be considered in the differential in those women with IBD and refractory abdominal pain. Given that these cysts are related to hormonal imbalances secondary to inflammation it is likely that these cysts would decrease in size or resolve with treatment of active IBD, as was seen in this patient. Further research into the incidence of ovarian cysts in IBD and effect of treatment of IBD on ovarian cysts is needed.