Unusual Case of Polypoid Mass in a Young Patient

Abstract

Purpose: 22 yr old white female, G2P1A1 with no medical co-morbidities was referred for management of left adnexal mass and elevated CA 125 level. She presented with a 2 month history of abdominal bloating, indigestion and night sweats. She denied any history of sexually transmitted disease or usage of intrauterine contraceptive device. Examination revealed tenderness in the left-lower quadrant of the abdomen. Basic laboratory work up was unremarkable. CA-125 was elevated at 347 U/ml(<35). Urine pregnancy test was negative. CT Pelvis confirmed the presence of a unilocular cystic mass in the left pelvic adnexa measuring 6.5 cm diameter, consistent with a left ovarian cyst with an adjancent mass measuring 5.8 × 4.8 × 5.4 cm. Stool occult blood was positive. Colonoscopy showed a polypoid mass at 22 cm which was 6 mm in diameter with hairy extrusions. It appeared to be extra-intestinal eroding into the colon. Mass was biopsied but not snare resected. Subsequently, patient underwent a left salphingo-oophorectomy, sigmoid colectomy and primary colonic anastomosis. Pathology confirmed the diagnosis of tuboovarian abscess with sigmoid perforation. Patient had uneventful recovery. Discussion: Tubo-ovarian abscess (TOA) is one of the more severe complications of pelvic inflammatory disease. It is formed by an inflammatory mass involving the fallopian tube, ovary and often surrounding structures. We believe this is the first presentation of a tubo-ovarian abscess perforating into the sigmoid colon and appearing as a polypoid mass on colonoscopy. There are reports of colonic involvement with perforation in other gynecological pathologies which include endometriosis, pelvic actinomycosis and ovarian malignancies including psuedomyxoma peritonnei. Endoscopist should stay vigilent as colonic malignancy at times can masquerade as an abscess.FigureFigure