Lower Abdominal Swelling Research Articles

Torsion of wandering spleen presenting as acute abdomen: A case report

Wandering spleen is a very rare condition characterized by the absence or weakness of one or more ligaments holding the spleen in its normal position. “Acquired” wandering spleen may occur during adulthood due to injuries or other underlying conditions that may weaken the ligaments that hold the spleen in its normal position. Torsion of a wandering spleen is an unusual cause of an acute abdomen and is rarely diagnosed preoperatively. Associated torsion of the distal pancreas is even more uncommon. We report a patient with torsion of a wandering spleen and distal pancreas presenting as acute abdomen with lower abdominal lump who was further diagnosed and managed.

A Rare Case of Leiomyomatosis Peritonalis Disseminata

Leiomyomatosis Peritonalis Disseminata (LPD), also known as disseminated peritoneal leiomyomatosis is an extremely rare disease in women and men where there is a rapid increase in peritoneal and subperitoneal nodules mainly of smooth muscle cells. It is a benign condition, however, its diagnosis can mimic or degenerate into peritoneal leiomyosarcoma, making the diagnosis tricky. In addition, clinical manifestations can be very nonspecific.
 We discuss the case of a 38-year-old nulliparous patient who presented to the clinic with a 2-year history of lower abdominal swelling and a 5-month history of severe menorrhagia. Intraoperative findings showed an enlarged uterus with subserosal fibroids and several deposits on the serosa and intestines. The patient had Total hysterectomy and bilateral-salpingoophorectomy. Because malignant transformation has been reported to potentially occur almost 10 years from initial diagnosis, patients should be monitored by repeat ultrasound scans.

Incisional Hernia Post Open Appendectomy: A Case Report

Incisional hernia is an unusual postoperative complication after appendectomy through a McBurney’s incision with an incidence of less than one percent. We present a case of incisional hernia post open appendectomy in a 40-year old woman. She presented to us with a painless right lower abdominal swelling that developed after an emergency open appendectomy for perforated appendix 7 years earlier. She was clinically stable with BMI of 24.5 kg/m2. She had a non-tender, reducible mass of 20×16×8 cm protruding through a healed right iliac fossa transverse scar. She had an open onlay mesh repair with satisfactory outcome. Post appendectomy incisional hernia is uncommon. Hernioplasty offers a satisfactory outcome.

Spigelian hernia with bilateral undescended (impalpable) testis in a child: rare scenario

Spigelain hernia (SH) is rarely seen in children. Various mechanisms has been described for the co-existence with cryptorchidism. A 4 month old boy, a known case of bilateral impalpable testes and intermittent right lower abdominal swelling was brought to paediatric emergency with complaints of excessive cry, poor feeding and irreducible right lower abdominal swelling - the swelling was a little higher than the usual inguinal hernia. On exploration, SH was seen coming off the deep ring then turning around the conjoint tendon and dissecting between internal oblique and external oblique aponeurosis. The hernia contained oedematous but viable gut with compression over the testicular vessels. Gut was viable. The testes was mobilized and fixed into the scrotum. Left testis was impalpable for which nubbin excision was done at a later date. A SH in the lower abdomen may be confused with a high inguinal hernia. In acute obstruction, emergent exploration and reduction is the cornerstone of treatment.

Primary hydatid disease of fallopian tubes: the risk of infertility looms large.

A 45-year-old postmenopausal woman from a rural area presented with a painless lower abdominal lump. Contrast-enhanced computed tomogram of abdomen revealed a well defined hypodense pelvic cystic lesion with multiple daughter cysts suggestive of hydatid disease. The liver was free of cysts on imaging. On laparotomy, the cyst cavity was found to be communicating with the fimbriated ends of both the fallopian tubes. Cyst excision along with hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathology confirmed presence of hydatid disease by demonstrating daughter cysts and laminated membrane completely filling up the tube lumens. The uterus and ovary were uninvolved. While the management is straightforward in postmenopausal women, the risk of infertility looms large in young patients with bilateral fallopian tube hydatid disease. Proper preoperative counseling is thus essential in the patients with pelvic hydatid disease to safeguard against future litigations.

Primary Ovarian Non-Hodgkin’s Lymphoma with Late Diagnosis Due to Unusual Presentation - A Case Report

Involvement of NHL in ovary is seen in disseminated Lymphoma but primary ovarian lymphoma still not commonly seen. We presented the case where the patient had suffered for unexplained fever for more than 1 year and lately presented with gross weight loss as well as painless lower abdominal lump. CT scan showed a huge heterogeneous mass of about 15x12.4cm in pelvic cavity with mild ascites. Surgery was performed in view of ovarian neoplasm as CA125 was also raised. Histopathology confirmed the diagnosis of diffuse large B cell lymphoma with Immunohistochemistry confirmation. Treated with R-CHOP protocol for 6 cycles as IHC expressed CD20 positive. Post chemotherapy follow up PET scan showed complete response of treatment, though in spite of all treatment Primary ovarian lymphoma have a poor outcome with a range from 0% to 36% expected to survive for less than three years.

Venous anastomosis procedure for treatment of lymphatic malformation in Klippel-Trenaunay syndrome

Abstract Klippel-Trenaunay syndrome (KTS) is a congenital vascular anomaly in children, which requires treatment but challenging. The characteristics of KTS include disproportionality of the affected limbs, usually with enlargement due to lymphatic malformation (LM) [1]. Sometimes the condition is accompanied by pain that is difficult to treat. Compression therapy is one option for reducing the swelling; however, this has limitations [2]. We previously reported that lymphatic venous anastomosis (LVA) may be a safe and effective procedure for reducing the size of micro cystic type LM by decreasing the intra cystic lymph [3]. We treated a case of KTS in a 9-year-old boy who had improvement of lower abdominal swelling and penile pain after a single LVA. The method involved is to make a bypass, from the afferent lymph-collecting vessel to subcutaneous veins. However, to apply LVA to LM, it is sometimes problematic to detect the afferent flow in combined vascular malformations, such as KTS. Therefore, we performed VA making a bypass directly from LM, instead. We classify two types of LVA methods for LM: afferent lymph vessel LMVA (A-LMVA), and sidewall LMVA (S-LMVA). S-LMVA has more merits than the previously reported A-LMVA.

Clinical Presentation of Infertility in Mkar-Gboko, North-Central Nigeria

Infertility is a worldwide health concern with dissimilarities in mode of presentation among couples. It is the commonest reason for gynaecological consultation in central Nigeria. Therefore there is need to appraise the clinical presentation of infertility and describe the manner of presentation by women in the region. Aim: To identify the mode of presentation and pattern of presenting complaints by women with infertility at a rural gynaecological outreach clinic. Method: A descriptive retrospective study at NKST Hospital Mkar-Gboko, north-central, Nigeria. Clinic records of patients who attended the outreach gynaecological clinic over eight years (1st January 2005 to 31st July 2013) were analysed using descriptive statistics with Excel 2010. Results: Of the 1,926 women studied, 1030 (53.5%) complained of inability to conceive, and 941 (92.0%) folders met inclusion criteria. Women with primary and secondary infertility were 264(28.1%) and 677(71.9%) respectively. The mean (±SD) age, parity and duration of infertility of the women were 31.5±5.9 year, 0.8±1.2, and 7 ±5 years respectively. The predominant complaints were inability to conceive, lower abdominal pain, abnormal menstruation, lower abdominal swelling and vaginal discharge. Majority of the women (55.0%) skipped inability to conceive as their chief complaint. In past surgical history, 194 (20.6%) of the women had 234 abdominal surgeries. On physical examination 538 (57.2%) of the women had no remarkable findings. Abdominal scar (n=194, 47.0%), enlargement of the uterus (n=166, 40.0%), vaginal discharge (n=42, 10.0%) were common findings. Conclusion: Non acute lower abdominal pain is a common mode of presentation of infertility in this population. The duration of marriage/age of last childbirth against the number of living children and contraceptive usage can be a clue to the woman’s desire.

Incarceration of sessile uterine fibroids in an incisional hernia in a postmenopausal woman: a case report

Incarceration of sessile fibroids in an incisional hernia is uncommon and can cause pain and discomfort. Very few cases have been reported in the literature but none in our region in women in the postmenopausal period. We present an uncommon case of a 57-year-old primipara with a previous history of caesarean section and a laparotomy on account of adhesive intestinal obstruction. She presented with lower abdominal swelling and abdominal pain since 7 years. She had surgical removal of the mass and total abdominal hysterectomy with mesh repair of the incisional hernia. Histology of the resected hernia content revealed leiomyoma. Abdominal wall fibroid is a good differential diagnosis to be considered in any woman with an anterior abdominal mass and previous uterine surgery, including caesarean section.

Primary Endometrial Squamous Cell Carcinoma In Situ: Report of a rare disease.

Squamous cell carcinoma (SCC) of the endometrium, whether primary or secondary to cervical cancer, is a rare entity. Primary endometrial squamous cell carcinoma in situ is even more uncommon; it usually occurs in postmenopausal women and has a strong association with pyometra. We report a 60-year-old multiparous postmenopausal woman who presented to the Hakeem Abdul Hameed Centenary Hospital, New Delhi, India, in May 2014 with a lower abdominal swelling corresponding in size to a pregnancy of 26 gestational weeks and vaginal discharge of one year's duration. A total abdominal hysterectomy with a bilateral salpingooophorectomy was performed, which revealed an enlarged uterus with pyometra. Histopathology showed that the entire endometrial lining had been replaced with malignant squamous cells without invasion of the myometrium. Immunohistochemistry revealed that the tumour cells were positive for p63 with a high Ki-67 labelling index. No adjuvant therapy was required and the patient was disease-free at a seven-month follow-up.

Reduced vaginal elasticity, reduced lubrication, and deep and superficial dyspareunia in irradiated gynecological cancer survivors

Purpose. The purpose of this study was to examine whether or not vaginal elasticity or lack of lubrication is associated with deep or superficial dyspareunia. We investigated gynecological cancer survivors treated with radiation therapy.Methods. In a population-based study with 616 women answering a questionnaire (participation rate 78%) and who were treated with radiotherapy for gynecological cancer, we analyzed information from 243 women (39%) who reported that they had had intercourse during the previous six months. Analyses included log-binomial regression (relative risks) and multiple imputations by chained equations in combination with Bayesian Model Averaging, yielding a posterior probability value. Age range of this cancer recurrent-free group of women was 29–80.Results. Dyspareunia affected 164 of 243 of the women (67%). One hundred thirty-four women (55%) reported superficial pain, 97 women (40%) reported deep pain, and 87 women (36%) reported both types of dyspareunia. The relative risk (RR) of deep dyspareunia was 1.87 (CI 1.41–2.49) with impaired vaginal elasticity compared to normal vaginal elasticity. Age and lower abdominal swelling were separate risk factors for deep dyspareunia. However, effects remain after adjusting for these factors.Conclusion. The relative risk of deep dyspareunia was almost twice as high with impaired vaginal elasticity compared to normal vaginal elasticity. If we wish to treat or even prevent deep dyspareunia in women with gynecological cancer, we may use our knowledge of the pathophysiology of deep dyspareunia and increasingly provide dilators together with instructions on how to use them for stretching exercises in order to retain vaginal elasticity. Results highlight the need for studies with more precise questions distinguishing superficial from deep dyspareunia so that in the future we may be able to primarily try to avoid reduced vaginal elasticity and secondarily reduce the symptoms.

English

An 11-year-old girl was admitted with abdominal pain and fever and a lower abdominal lump. Clinically acute appendicular mass was strongly suspected. Computed tomographic scan showed a dilated intestinal loops and a fecolith proximal to it. On laparotomy a giant cecal diverticula was found and diverticulectomy was performed. We report this rare case of a giant cecal

Imperforate Hymen Presenting with Massive Hematometra and Hematocolpos: A Case Report

Background: Imperforate hymen is the commonest congenital anomaly that causes closure of the vagina. Ideally, diagnosis should be made early during fetal and neonatal examinations to prevent symptomatic presentations of its complications at puberty. Case report: We report a case of a 15-year-old girl who presented with delayed menarche, eight-month history of cyclic abdominal pain, and a three-week history of lower abdominal swelling. A doctor prescribed anthelmintic and analgesic drugs to her a month ago before she was verbally referred to ESUT Teaching Hospital, Enugu. The development of her secondary sexual characteristics was normal for her age. A 20 cm-sized suprapubic mass, and a bulging pinkishimperforate hymen were found on examination. Her transabdominal ultrasound revealed massive hematometra and hematocolpos. She had virginity-preserving hymenotomy and evacuation of about 1000 mls of accumulated coffee-colored menstrual blood. Conclusion: Clinicians should have high index of suspicion of imperforate hymen when assessing cases of delayed menarche with cyclic lower abdominal pain to prevent the consequences of its delayed treatment like massive hematometra and hematocolpos.

Clinlcopathological Study of Ovarian Cancer: A Multi Centered Study

Background: Ovarian cancer is one of the leading causes of morbidity and mortality. Objectives: The purpose of the present study was to find out clinic-demographic and histopathological variants of ovarian cancer. Methodology: This cross-sectional study was conducted in the Department of Obstetrics and Gynaecology at four largest tertiary care Hospitals in Dhaka city from January 2008 to December 2009. Clinically diagnosed and histopathologically confirmed ovarian cancer patients were included in this study. Result: Histopathological confirmed 28 patients of ovarian cancer were enrolled in this study. The mean age (±SD) was 40.6 (±12.5) years (Range 13 to 63 years). Lower abdominal lump (71.4%) was the most common symptoms. Family history (14.0%) and multiparty (53.0%) were also associated with ovarian cancer. Among 28 malignant tumors cases serious cyst adenocarcinoma (57.1%) was the most common followed by mucinous cyst adenocarcinoma (17.9%), dysgerminoma (7.1%), adenocarcinoma of ovary (7.1%), ovarian choriocarcinoma (3.6%) and endometriod adeno carcinoma (3.6%). High serum CA125 was found in 78.0% cases. Conclusion: Lower abdominal lump, multiparity and positive family history are the common clinical findings of ovarian cancer. Both serous and mucinous cyst adenocarcinoma are the common varient of ovarian cancer found in this study. DOI: http://dx.doi.org/10.3329/jssmc.v5i1.16196 J Shaheed Suhrawardy Med Coll, 2013;5(1):3-6

A rare case of malignant acanthosis nigricans in a lady with ovarian cancer

“Tripe palms” or pachydermatoglyphy is a descriptive term of acanthosis nigricans of the palms and is associated with internal malignancy. It often precedes the diagnosis of a new or recurrent tumor. Malignant acanthosis nigricans is most commonly associated with intra-abdominal malignancies. In patients with both tripe palms and acanthosis nigricans, gastric carcinoma is the most common followed by lung carcinoma. There are very few reports in the literature of malignant acanthosis nigricans associated with gynecological malignancies. We report this case because of its rarity. A 47-year-old lady presented with lower abdominal swelling and progressive hyperpigmentation which preceded the abdominal swelling by 6 months. On investigations, she was found to have ovarian cancer. The presence of acanthosis nigricans in conjunction with tripe palms in a female patient is highly suggestive of an internal malignancy including an ovarian cancer and demands an extensive search for the hidden ovarian cancer.

Lower Abdominal Swelling and Scrotal Enlargement

A24-YEAR OLD MAN REPORTS PROGRESSIVE, RIGHT LOWER ABDOMINAL SWELLing and right scrotal enlargement over 2 years. He denies any pain or sudden changes in the size of the swelling. There is no history of trauma or urinary symptoms. Physical examination reveals a smooth, fluctuant, right abdominal swelling extending from the level of the umbilicus to the inguinal ligament (FIGURE 1). There is also a smooth, cystic swelling causing marked enlargement of the right half of the scrotum. There is no local warmth or tenderness. The left testis is within the scrotum, but the right testis is not palpable. When the patient is asked to cough, there is a palpable thrill. Palpation of the abdominal and scrotal swellings simultaneously reveals cross-fluctuation. Both the swellings are transilluminant. What Would You Do Next?

The benefit of myomectomy in women aged 40 years and above: Experience in an urban teaching hospital in Nigeria

Background:Abdominal myomectomy remains the mainstay of surgical management of uterine fibroids in our environment. However, its benefit in women aged 40 years and above remains debatable.Materials and Methods:An 11-year prospective study was conducted involving 98 women, aged 40 years and above, who had abdominal myomectomy for the treatment of uterine fibroid at the University of Maiduguri Teaching Hospital, Maiduguri. They were followed up regularly for 1–6 years to detect conception, resolution of symptoms and obstetrics performance. Data were analyzed using SPSS version 13.Results:The mean age of the patients was 42.6±2.9 years and 77 (78.6%) of them were nulliparous. Lower abdominal swelling was the commonest clinical presentation and the mean uterine size was 18.6±8.5 weeks. Infertility with uterine fibroids was the indication for myomectomy in majority of the cases [48 (48.9%)], while pregnancy complications accounted for 11.2% (11) of the cases Fertility restoration was 10.4% among the infertile patients. There was complete resolution of symptoms in 35.9% of those who required symptomatic relief, and term pregnancies were recorded in 72.7% of patients with pregnancy complications.Conclusion:Myomectomy is the recommended treatment of uterine fibroids in women aged 40 years and above with infertility and who wish to become pregnant. If there is no need for further fertility preservation, hysterectomy should be offered.

Primitive neuroectodermal tumor of uterus — A rare entity

Primitive neuroectodermal tumor (PNET) of uterus is the rare of the rarest among the tumors of female genital tract. We herein reported a 32 years old female operated for lower abdominal lump, which was diagnosed, as PNET later confirmed by immunohistochemistry (IHC). She was lost to follow-up and presented 10 months later with recurrence. She was treated with cyclical combination chemotherapy followed by definitive surgery and is in complete remission at present.

Mesenteric cyst: an unusual presentation

A 5-year-old boy presented with the history of a small lower abdominal swelling since childhood which increased in size and became painful following a fall. Examination revealed a mobile, globular, cystic intraabdominal mass in the lower abdomen. Ultrasonography of the abdomen suggested a 7.5 × 5.5 cm cystic lesion, separate from the bladder, containing an echogenic mobile mass. Intra venous urography excluded any abnormality of the kidneys, ureters and bladder. Exploratory laparotomy revealed a sigmoid mesenteric cyst protruding out of one of the mesenteric leaves and attached to it by a narrow stalk. The excised cyst was found to be thin walled and unilocular. It was internally lined with fibrinous exhudate and contained serous fluid and a solid spherical blood clot. The child had an uneventful postoperative recovery. Histopathology of the cyst wall showed maturing granulation and fibrous tissue with hemosiderin laden macrophages and lymphoid aggregates consistent with the diagnosis of a lymphagioma with chronic inflammatory changes and evidence of past hemorrhage.

Intermittent Urinary Retention Secondary to a Cervical Leiomyoma

A rare case of intemittent acute urinary retention secondary to impacted posteriorly sited cervical fibroid in a 34 year old nulliparous woman is deescribed. She presented with a two year history of progressive lower abdominal swelling and a one year history of recurrent urinary retention. She had a preoperative diagnosis of impacted posteriorly sited uterine leiomyoma with anterior displacement of the cervix. At laparotomy however, a huge intramural cervical fibroid was found in the posterior part of the cervix measuring 14cm? 12cm extending superiorly to the lower uterine segment and inferiorly into the pouch of Douglas. It completely filled the pelvis and displaced the cervix anteriorly. The uterus was of normal size. A myomectomy with excision of the fibroid was performed. Urinary retention completely resolved after surgery.