Young Woman With Abdominal Pain

Abstract

A previously healthy 22-year-old woman presented to the emergency department with worsening abdominal pain and emesis for 3 days. Her vital signs were normal. Physical examination revealed a tender mass suspicious for hepatomegaly, extending from the right upper quadrant to the midabdomen. There was no guarding or rebound tenderness on examination. Laboratory study results were unremarkable and serum pregnancy test was negative. Contrast-enhanced computed tomography (CT) was performed (Figure 1, Figure 2, Figure 3).Figure 2CT (axial view) demonstrating soft tissue, bone, and fat-density elements within the superior multiloculated mass (between arrowheads).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3CT (axial view) demonstrating soft tissue, bone, and fat-density elements within the inferior multiloculated mass, between the rectum (black arrow) and vagina (white arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Bilateral benign cystic teratomas with right ovarian torsion. The coronal and axial CT views show 2 heterogeneous masses, one in the midabdomen and the other in the pelvis, with internal components of fat, soft tissue, and bone consistent with benign cystic teratomas. The patient was taken to the operating room, where intraoperative examination demonstrated bilateral abdominopelvic masses arising from the left and right ovary, with right ovarian torsion. The masses contained fat, hair, and bone on gross examination and were removed with preservation of ovarian tissue (Figure 4). Benign cystic teratomas are tumors of well-differentiated derivations from at least 2 of the 3 germ cell layers.1Comerci Jr., J.T. Licciardi F. Bergh P.A. et al.Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature.Obstet Gynecol. 1994; 84: 22-28PubMed Google Scholar, 2Outwater E.K. Siegelman E.S. Hunt J.L. Ovarian teratomas: tumor types and imaging characteristics.Radiographics. 2001; 21: 475-490Crossref PubMed Scopus (409) Google Scholar Teratomas are the most common germ cell neoplasm and generally affect a younger age group (mean age 30 years).2Outwater E.K. Siegelman E.S. Hunt J.L. Ovarian teratomas: tumor types and imaging characteristics.Radiographics. 2001; 21: 475-490Crossref PubMed Scopus (409) Google Scholar They are bilateral in approximately 10% of cases.3Park S.B. Kim J.K. Kim K.R. et al.Imaging findings of complications and unusual manifestations of ovarian teratomas.Radiographics. 2008; 28: 969-983Crossref PubMed Scopus (107) Google Scholar Most teratomas are asymptomatic, with abdominal pain or other nonspecific symptoms occurring in the minority of patients.1Comerci Jr., J.T. Licciardi F. Bergh P.A. et al.Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature.Obstet Gynecol. 1994; 84: 22-28PubMed Google Scholar Teratomas can be associated with complications, including rupture, malignant degeneration, or, most commonly, ovarian torsion (3.2% to 16%). Larger teratomas, greater than 6 cm, are more likely to undergo torsion.1Comerci Jr., J.T. Licciardi F. Bergh P.A. et al.Mature cystic teratoma: a clinicopathologic evaluation of 517 cases and review of the literature.Obstet Gynecol. 1994; 84: 22-28PubMed Google Scholar