Pelvic Ascites Research Articles

Utility of Combined Use of Imaging Features From Abdominopelvic CT and CA 125 to Identify Presence of CT Occult Peritoneal Metastases in Advanced Gastric Cancer.

The purpose of this study is to identify the presence of occult peritoneal metastasis (OPM) in patients with advanced gastric cancer (AGC) by using clinical characteristics and abdominopelvic computed tomography (CT) features. This retrospective study included 66 patients with OPM and 111 patients without peritoneal metastasis (non-PM [NPM]) who underwent preoperative contrast-enhanced CT between January 2020 and December 2021. Occult PMs means PMs that are missed by CT but later diagnosed by laparoscopy or laparotomy. Patients with NPM means patients have neither PM nor other distant metastases, indicating there is no evidence of distant metastases in patients with AGC. Patients' clinical characteristics and CT features such as tumor marker, Borrmann IV, enhancement patterns, and pelvic ascites were observed by 2 experienced radiologists. Computed tomography features and clinical characteristics were combined to construct an indicator for identifying the presence of OPM in patients with AGC based on a logistic regression model. Receiver operating characteristic curves and the area under the receiver operating characteristic curve (AUC) were generated to assess the diagnostic performance of the combined indicator. Four independent predictors (Borrmann IV, pelvic ascites, carbohydrate antigen 125, and normalized arterial CT value) differed significantly between OPM and NPM and performed outstandingly in distinguishing patients with OPM from those without PM (AUC = 0.643-0.696). The combined indicator showed a higher AUC value than the independent risk factors (0.820 vs 0.643-0.696). The combined indicator based on abdominopelvic CT features and carbohydrate antigen 125 may assist clinicians in identifying the presence of CT OPMs in patients with AGC.

Abstract 4808: Small intestinal leiomyosarcoma in a young adult

Abstract Objectives: • Outline the epidemiology of leiomyosarcoma•Identify the immunohistochemistry of a leiomyosarcoma Introduction: Primary small intestinal malignancies are rare malignancies as compared with other malignancies of the gastrointestinal tract. Here, we present a case of a jejunal leiomyosarcoma in a young adult. Case Presentation: A 23-year-old Caucasian male with GERD presented with five months of abdominal pain, intermittent nausea with non-bloody emesis, and a 20-pound weight loss. Presenting vital signs were within normal limits. Physical exam revealed conjunctival pallor with epigastric tenderness to palpation. Serology demonstrated iron deficiency anemia, hemoccult positive stool, negative CEA, CA19-9, and AFP tumor markers. HIV antigen antibody and EBV-PCR were non-reactive. CT of the abdomen and pelvis revealed markedly thickened heterogenous jejunal loop in the left hemiabdomen with associated mesenteric adenopathy and small volume pelvic ascites. EGD with push enteroscopy revealed a single, malignant appearing and ulcerated mass in the proximal jejunum. PET-CT showed a hypermetabolic, multilobulated, ill-defined mass involving multiple loops of jejunum. He underwent exploratory laparotomy with resection of a proximal jejunal mass (10x8 x7 cm), mesenteric lymphadenectomy, and a jejunojejunostomy creation. Pathology demonstrated leiomyosarcoma (pT2aN0MoG3), and he was initiated on cyclophosphamide and doxorubicin. Discussion: Primary small intestinal malignancies are rare malignancies with an incidence of less than 5% of all GI malignancies. 56 cases of GI leiomyosarcoma in adults were identified between 2000-2012 with a peak incidence between 55-59 years of age (Aggarrwal 2012). Leiomyosarcomas are soft tissue sarcomas arising from bones, tendons, blood vessels, or muscles with a spectrum of disease ranging from low-grade cutaneous lesions to aggressive lesions of internal organs with significant potential for metastasis (Pipe 2002). Diagnosis is based on immunohistochemical positivity for SMA, desmin, and h-caldesmon, and negativity for CD117, CD34, and DOG1.1, notably lacking KIT and PDGFRA mutations (Aggarwal 2012). Treatment involves surgical resection and a cost benefit analysis of adjuvant chemotherapy with (Reynolds, 2014). This case of a 23 year old, without significant risk factors, diagnosed with a jejunal leiomyosarcoma presents as one of the youngest cases ever to be reported and emphasizes the importance of recognizing the cancer in a broader range of the adult population. Citation Format: Alyssa A. Guo, Blake H. Bentley, Abigail L. Ellington, Haiyan Lu, William C. Lippert. Small intestinal leiomyosarcoma in a young adult [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4808.

Serous surface papillary borderline tumor of ovary – An underdiagnosed entity

A young female presented with complaints of dysmenorrhea for 8 months. Ultrasound of the pelvis showed an echogenic mass in the left adnexa with papillary projections and internal vascularity and encasing the left ovary. Subsequent magnetic resonance imaging (MRI) showed an intensely enhancing, lobulated solid mass with a frond-like appearance, and papillary projections surrounding the left ovary reminiscent of a “sea-anemone.” The right ovary showed a cystic lesion without enhancing papillary projections or mural nodules. There was mild pelvic ascites and few peritoneal nodules in the pelvis. The presumptive radiologic diagnosis was serous surface papillary borderline tumor (SSPBT) of the left ovary and a benign cyst in the right ovary. The patient was treated with the left salpingo-oophorectomy, right ovarian cystectomy, peritoneal, and omental biopsies. Histopathology confirmed the diagnosis of SSPBT of the left ovary with microinvasion (<5 mm) of the ovarian surface. The right ovarian cyst was a follicular cyst. The peritoneal biopsies were positive for implants from SSPBT. This report highlights the diagnostic utility of “sea-anemone” sign and reviews the clinical and radiopathologic features of SSPBT.

Efficacy of Dan'e Fukang Soft Extract in Moderate Ovarian Hyperstimulation Syndrome for Concurrent Treatment of Blood and Fluid Guided by the "Triple Prevention" Principle.

This study aimed to evaluate the therapeutic efficacy and safety of Dan'e Fukang soft extracts in moderate ovarian hyperstimulation syndrome (OHSS) for the simultaneous treatment of blood and fluid, guided by the traditional Chinese medicine principle of "triple prevention". This study conducted a retrospective analysis of clinical data from outpatients who underwent in vitro fertilization (IVF)/intracytoplasmic sperm injection embryo transfer (ICSI-ET). A total of 2245 cases were included and divided into a treatment group (1002 cases) and a control group (1243 cases). Patients in the treatment group were administered Dan'e Fukang soft extracts orally in addition to conventional Western medicine. Comparative assessments were made between the two groups on pelvic ascites volume, maximum ovary diameter, dysmenorrhea incidence post-oocyte retrieval, and safety indicators. There were no statistically significant differences between the treatment group and the control group in terms of general characteristics or the levels of follicle-stimulating hormone (FSH), luteotropic hormone (LH), estradiol (E2), or progesterone (P) at the time of gonadotropin (Gn) initiation. The groups did not differ significantly when we compared the levels of LH, E2, or P on the day of human chorionic gonadotropin (hCG) injection and during ovarian hyperstimulation protocols (P > 0.05 for all indicators). The differences in the volume of pelvic ascites, the maximum ovarian diameter, and the incidence of dysmenorrhea after oocyte retrieval were statistically significant between the treatment group and the control group (P < 0.05 in both). There were no instances of adverse reactions in either group. Based on the traditional Chinese medicine principle of "triple prevention", the use of Dan'e Fukang soft extracts for the simultaneous treatment of blood and fluid in moderate OHSS significantly improved the absorption of pelvic ascites, promoted ovarian recovery, and reduced the incidence of dysmenorrhea after oocyte retrieval.

Early short-term abdominal paracentesis drainage in moderately severe and severe acute pancreatitis with pelvic ascites

BackgroundWe sought to evaluate the effect of early short-term abdominal paracentesis drainage (APD) in moderately severe and severe acute pancreatitis (MSAP/SAP) with pelvic ascites.MethodsA total of 135 MSAP/SAP patients with early pelvic ascites were divided into the Short-term APD group (57 patients) and the Non-APD group (78 patients). The effects, complications, and prognosis of short-term APD patients were evaluated.ResultsThe baseline characteristics in the two groups were similar. The target days of intra-abdominal hypertension relief, half-dose enteral nutrition, duration of mechanical ventilation, length of intensive care unit stay (in days) and total hospitalization (also in days) were all lower in the Short-term APD group than in the Non-APD group (P = 0.002, 0.009, 0.004, 0.006 and 0.019), while the white blood cell count and serum C-reaction protein level decreased significantly more quickly (P < 0.01 and P < 0.05), and the prevalence of intra-abdominal infection was also significantly lower (P = 0.014) in the former than the latter. No complications occurred in early APD patients, and the microbial cultures of pelvic ascites were all negative. In addition, patients with early APD presented fewer cases of residual wall-off necrosis or fluid collection (P = 0.008) at discharge and had a lower incidence of rehospitalization and percutaneous catheter drainage and/or necrosectomy (P = 0.017 and 0.009).ConclusionsFor MSAP/SAP patients with pelvic ascites, the early short-term APD is feasible and safe to perform, and it can decrease clinical symptoms, reduce intra-abdominal infection and shorten the hospital stay. It may also reduce the incidence of rehospitalization and surgical intervention.

Emergency laparoscopic surgery on a patient who visited the emergency room with lower abdominal pain

Internal hernias account for fewer than 6% of all small intestinal obstructions; of these, hernias caused by defects in the sigmoid colon are particularly challenging to detect. Misdiagnosis may occur if non-surgical symptoms (such as rebound tenderness) are not observed in the emergency room. We report the case of a consent who visited the emergency room with recurrent non-specific lower abdominal pain. She exhibited an internal hernia that had triggered small intestinal ischemia between the mesosigmoid (mesentery) and ovary. A 36-year-old female patient visited the emergency room of our hospital with acute left-lower abdominal pain, nausea, and vomiting that occurred 1 h after meals. We found no palpable mass or enlarged organ. Abdominal computed tomography (CT) revealed segmental small bowel wall thickening with mesenteric congestion in the left-lower quadrant, and small bowel ischemia attributable to internal herniation or adhesion. In addition, a small amount of pelvic ascites and multiple liver cysts were observed. A surgeon was immediately consulted and emergency laparoscopic surgery was performed.

8880 Recurrent Endometriosis-Associated Massive Hemorrhagic Ascites: A Case Report and Literature Review

<h3>Study Objective</h3> To discuss the presentation, pathophysiology, and management of large-volume endometriosis-related ascites. <h3>Design</h3> Case report and literature review. <h3>Setting</h3> University-based teaching hospital. <h3>Patients or Participants</h3> A 31-year-old with cyclic pelvic pain presented with new-onset hemorrhagic ascites up to 6L in volume requiring recurrent paracentesis. <h3>Interventions</h3> Initial ultrasound imaging (Figure 1) revealed large volume ascites, normal uterus, and normal ovaries. Computed tomography scan revealed a large amount of ascites with a normal-appearing liver. Paracentesis revealed hemosiderin laden macrophages and no evidence of malignancy or bacterial growth. The patient's medical and hepatologic workup was unremarkable. After undergoing two additional paracentesis procedures, she underwent diagnostic laparoscopy and peritoneal biopsies. Findings included stage 4 endometriosis with posterior cul-de-sac disease, right adnexal and large bowel disease, and diaphragmatic disease (Figure 2). <h3>Measurements and Main Results</h3> The patient was started on high-dose oral progestins postoperatively. Thereafter, she noted symptom improvement and less frequent paracentesis, but stopped therapy due to side effects. She was started on Elagolix and add-back therapy with no recurrence of ascites over one month of follow-up. Large-volume endometriosis-associated ascites is rare, usually recurrent, and thought to be due to massive ovarian transudate plus altered lymphatic drainage¹. Symptoms may mimic those of an ovarian malignancy. Associated CA-125 levels vary and do not correlate with the presence of ascites^2,3. Additionally, 38% of patients present with pleural effusion². Suppressive therapy with gonadotropin-releasing hormone (GnRH) agonists temporarily prevents ascites recurrence, but medical management regimens and outcomes vary^1,3,4. Surgical management of endometriosis without bilateral salpingo-oophorectomy (BSO) is associated with a recurrence rate of over 50%, while BSO is curative¹. <h3>Conclusion</h3> Clinicians should consider endometriosis in the workup for patients presenting with pelvic pain and recurrent large-volume hemorrhagic ascites after ruling out ovarian malignancy. Suppressive therapy with high-dose progestins or GnRH agonists/antagonists may improve symptoms and reduce the risk of recurrent ascites, but rigorous studies are lacking.

Appendicular mass with pseudomyxoma peritonei: a case report

Pseudomyxoma peritonei is an infrequently occurring clinical entity having an annual incidence of less than two per million. It is originated from the rupture of a tumour filled with mucinous substance. The intra-abdominal viscera are usually covered with a jelly-like substance. This syndrome originates most frequently from tumours of the appendix or ovaries. Genetic history is expected to play a role in the appendicular mucocele. The disease advances due to the presence of microbial agents expressed in carcinomas associated with gelatinous ascites. It typically has an insidious onset with a non-exclusive presentation like an increase in abdominal girth and associated abdominal pain with locoregional dissemination initially and dissemination to multiple sites later. The main sign is pelvic ascites. Diagnosis is made by combining radiological imaging with histopathology. Ultrasound aids in identifying the pelvic mass, peritoneal implants, calcifications, effusion, septa, the associated tumours (e.g., ovaries), the involvement of mesentery, and finalizing the surgical strategy. Usually, this condition is adequately treated by combining surgical excision and/or hyperthermic intra-peritoneal chemotherapy (HIPEC), which may be omitted by selecting the patient carefully.

S3566 Birthing a Baby or Surfacing a Hidden Tumor?

Introduction: Malignancy is a rare finding during pregnancy and if present, often carries poor prognosis. We present to you a case of Krukenberg tumor- a metastatic malignancy of the ovary- in a 29 year old female. Case Description/Methods: A 29-year-old female with no past medical history, presented to the hospital with preterm labor at 30 weeks gestation which lead to low transverse caesarian delivery secondary to recurrent prolonged decelerations and preterm contractions. Patient had an uneventful pregnancy course until this hospitalization. Intraoperatively, a large right sided ovarian mass was discovered. Tissue pathology revealed metastatic poorly differentiated adenocarcinoma. CT scan of the abdomen pelvis was suggestive of right adnexal mass measuring 10 × 14 × 13 cm with increased vascularity, large degree of abdominal pelvic ascites, with few lymph nodes in the upper mesenteric arcade, along with moderate thickening of the gastric wall. Esophagogastroduodenoscopy (EGD) revealed a gastric mass at cardia (Figure a), and tissue pathology was consistent with adenocarcinoma with presence of signet ring cells (Figure b). Additional work up was positive for elevated CA 125 and AFP tumor marker measuring 355 U/ml and 10.8 U/ml, respectively. Subsequent follow up with CT abdomen revealed bilateral ovarian metastasis with large volume ascites. Diagnostic paracentesis was negative for malignant ascites. Clinical course was complicated by recurrent ascites and progressive clinical deterioration. Due to poor performance status, the patient did not undergo any surgical intervention. Patient is currently being managed with palliative chemotherapy and paracentesis for symptomatic relief. Discussion: Krukenberg tumor is a metastatic malignancy of the ovary which is characterized by mucin-rich signet-ring adenocarcinoma that arises primarily from a gastrointestinal site. It accounts for almost 1%–2% of all ovarian tumors. The incidence of gastric cancer in the women of reproductive age group is 0.4%–0.5%, making these tumors extremely rare during pregnancy. Pregnancy symptoms masks the presence of the disease leading to diagnosis at a later stage. Unfortunately, no optimal treatment strategy for these tumors have been identified so far. Chemotherapy as well as radiation therapy does not seem to have any significant role in the prognosis of these patients. Due to metastatic nature and lower rate of resectability, surgery is deferred as it does not offer any increased survival time. The overall prognosis remains poor.Figure 1.: (a) EGD revealing gastric mass at cardia (b) Tissue pathology showing adenocarcinoma with presence of signet ring cells.

Abdominal tuberculosis mimicking ovarian cancer. A case series report.

Peritoneal tuberculosis (abdominal tuberculosis) can be confused with a malignant neoplasm. To describe clinical and demographic characteristics of patients with abdominal tuberculosis mimicking advanced ovarian cancer, diagnosed in a national reference cancer center. Clinical and pathological characteristics of nine patients with abdominal tuberculosis that clinically resembled advanced ovarian cancer are described. Median age was 47 years; the most common socioeconomic status was low (44%). Abdominal pain and weight loss occurred in 77.7%; ascites, in 55.5%; 22.2% had a positive COMBE test, and 100% had no history of pulmonary tuberculosis. CA-125 elevation was reported in 77.7%, with levels > 500 U/mL in 57.1%. Tomography reported carcinomatosis in 50% and pelvic tumor and ascites in 37.5%. All patients underwent surgery, where 62.5% were diagnosed by intraoperative pathology study as neoplastic disease. Tuberculosis is considered the great imitator, which is why abdominal tuberculosis diagnosis should be borne in mind when faced with a suspicious case, even when clinical presentation, imaging studies, and even intraoperative examination suggest ovarian cancer.

Role Of Ultrasound For The Diagnosis Of Complications Of Dengue Fever In Gujrat

Background : The purpose of this study is to evaluate if ultrasonography may be used as an useful addition to clinical and radiology profiles in diagnosing dengue fever and predicting virus severity by comparing imaging findings. The difference in sonographic characteristics observed in patients of various ages was also investigated. &#x0D; Objective : The goal of this study is to determine role of ultrasound for diagnosis of complications of dengue fever in Gujrat &#x0D; Materials and Methods: This is a retrospective study. From October and December 2021, 79 patients who were serologically confirmed with dengue fever were referred for ultrasound scanning of the abdomen at Aziz bhatti shaheed hospital Gujrat, and the imaging data were evaluated. The statistical kit for social science (spss) is used for data analysis.&#x0D; Results: out of 76 positive dengue patients there are 71(89.9%) male and 8(10%) are female .48 (60.8%) patients showed splenomegaly, 24(30%) patients showed ascites in which 8 (10%) have pelvic ascites and 16 (20.3%) abdominal ascites, 63 (79.7%) patients showed edematous GB wall thickening, 21(26.6%) showed pleural effusion while 18 (22.8 %) have bilateral pleural effusion and 3 (3.8%) have right sided. &#x0D; Conclusion: In patients presenting with fever and concomitant symptoms, sonographic signs of thickening GB wall, pleural effusion (bilateral or right side), ascites, and splenomegaly should strongly help in early diagnosis of dengue fever, especially during an outbreak. &#x0D;

Abdominal CT findings in Puumala hantavirus-infected patients.

Previous clinical studies have reported abdominal findings on ultrasonography or MRI in Puumala hantavirus-infected patients. To determine if abdominal computed tomography (CT) can lead to a diagnosis of Puumala virus infection in the presence of a suggestive clinical picture. CT findings were studied retrospectively in 30 patients who presented to the emergency department of two (Belgian) hospitals with serologically confirmed Puumala hantavirus infection. The most frequent finding was perirenal fascial thickening (90%), followed by perirenal fat stranding (87%). Retroperitoneal fat stranding was found in 19 patients (64%) in the perivesical spaces along the fascia of the external iliac vessels with or without involvement of the presacral fat. Half of the patients had pelvic ascites, and pleural fluid was found in 7 of them. The right and left mean pole-to-pole kidney's lengths were respectively 125.7mm and 127.8mm in 28 patients. Retroperitoneal fat stranding, perirenal fascial thickening and/or perirenal fat stranding were found in most patients with acute Puumala virus infection who have undergone CT. Although nonspecific, these findings may help to suggest Puumala hantavirus infection in the right clinical settings.

Duodenal Adenocarcinoma – A Rare Encounter and Management in a Young Male

Duodenal Adenocarcinoma (DA) is a rarely encountered tumor. It usually resides in the elderly, diagnosed at an average age of 60 years. The malignancy has a poor outcome with 5-year survival at 30%. DA along with peritoneal dissemination in a subset of the younger population has not been well reported in the literature review so we intend to report this case. We report a case of a patient with Duodenal Adenocarcinoma (DA). The carcinoma was diagnosed in the third segment of the duodenum with associated peritoneal carcinomatosis. The patient presented with abdominal pain, nausea, weight loss, and other symptoms with a history of cholecystectomy for his prior abdominal complaints. A large obstructive ulcerated mass in the third segment of the duodenum (D3) confirmed the presence of a DA. A palliative gastrojejunostomy was performed with a subsequent Whipple procedure ahead concomitantly with hyperthermic intraperitoneal chemotherapy (HIPEC). After surgery, the patient presented with post-operative complications including pelvic and abdominal ascites with perforation of the sigmoid colon. On subsequent follow-ups, he did well but with a recurrence in the form of lung nodules a year after the Whipple’s procedure. DA is one of the rarest malignancies ever encountered and is significantly scarce in the younger subset. The key to a successful outcome involves an aggressive approach with an early diagnosis. Lymph node assessment has been pivotal as an important prognostic factor. No positive correlation has been established between adjuvant chemotherapy and survival rates. Peritoneal dissemination from DA appears to be sparse. HIPEC, although a reasonable therapeutic strategy for disseminated peritoneal carcinomatosis, resulted in sigmoid perforation.

S1942 Microscopic Hematuria Leading to the Diagnosis of Appendiceal Mucinous Carcinoma

Introduction: Appendiceal mucinous neoplasms (AMNs) are an exceedingly rare gastrointestinal malignancy with in incidence of 2.8 cases per million, accounting for less than 1% of all GI cancers, and approximately 1,500 new cases in the US annually. AMNs typically present as acute appendicitis, given the predilection for appendiceal perforation, however as many as 23% are incidentally diagnosed. They are generally thought to be indolent compared to their colorectal counterparts and rarely metastasize outside of the peritoneum. Case description/methods: A 71-year-old female with a 6 pack-year smoking history and long-term methotrexate use for lichen planus presented to her PCP’s office for her annual evaluation. Routine urinalysis at that time showed microscopic RBCs so CT abdomen/pelvis was ordered and showed a 7.9 × 4.8 × 5.1 cm complex right adnexal cyst with adjacent free fluid. Subsequent pelvic ultrasound re-demonstrated the same plus a thickened 6 mm endometrial strip. MRI pelvis was pursued and showed this large adnexal cystic mass to be contiguous with the tip of the appendix, in addition to multiple uterine fibroids. After an unremarkable cystoscopy, suspicions were raised for an exophytic ovarian neoplasm, so the patient proceeded with laparoscopic bilateral salpingo-oophorectomy, appendectomy, collection of pelvic ascites, peritoneal biopsies and liver serosa biopsy, hysteroscopy and endometrial polypectomy. Intraoperatively, the patient had a mucinous fluid covering her pelvic and abdominal cavity with normal appearing uterus, and a ruptured 6 cm complex mass encompassing the appendix. Pathology revealed low grade primary appendiceal mucinous carcinoma with rupture and mucin extravasation, without gynecologic dysplasia. Colonoscopy was then done and only a 3 mm sessile polyp with benign morphology was found in the descending colon. PET CT showed no evidence of metastatic disease. The hospital course was complication by septic shock with polymicrobial bacteremia requiring prolonged mechanical ventilation and tracheostomy. She was discharged to an acute rehab hospital around 8 weeks later, and at 6-month follow-up had no disease recurrence. Discussion: Demonstrated is of the many potential red herrings observed in the evaluation of invasive GI cancers, emphasizing the importance of maintaining broad differentials and an interdisciplinary approach. Also unique was the lack of substantial symptoms despite rupture of said AMN and peritoneal spread - often an acutely clinically significant and painful event.Figure 1.: Figure A: Whirl sign on CT, with a dilated descending colon. Figure B-C: Benign-appearing, intrinsic twisted stenosis in the descending colon. Markedly dilated descending colon after a gentle advance of the colonoscope. The rectal tube was navigated proximal to the volvulus area. Figure D: Abdominal x-ray showing resolution of massive colonic distension after detorsion and rectal tube placement.

Prevalence and Clinical Implications of Ascites in Gastric Cancer Patients after Curative Surgery.

We aimed to determine the frequency and clinical significance of ascites that developed during the follow-up period in patients who underwent curative resection for gastric cancer. The study included 577 patients with gastric cancer who underwent curative gastrectomy. Among them, 184 showed ascites in postoperative follow-up images. Benign ascites was observed in 131 of 490 patients without recurrence, 48 patients (of 87) with recurrence had malignancy-related ascites, and the remaining 5 patients had ascites only prior to recurrence. In most patients without recurrence (97.7%) and in 50% of patients with malignancy-related ascites, the ascites was small in volume and located in the pelvic cavity at the time that it was first identified. However, with the exception of nine patients, malignancy-related pelvic ascites occurred simultaneously or after obvious recurrence. Of those nine patients who had minimal pelvic ascites before obvious recurrence, only one had a clear association with a malignancy-related ascites. In the multivariate analysis, an age of ≤45 was the only independent risk factor for the occurrence of benign ascites. A small volume of pelvic ascites fluid is common in young gastric cancer patients who do not have recurrence after gastrectomy, regardless of sex. It is rare for ascites to be the first manifestation of recurrence.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Electrocardiogram Findings Associated With Malignant Pericardial Effusion and Cardiac Tamponade.

Pelvic mass, ascites, hydrothorax: a malignant or benign condition? Meigs syndrome with high levels of CA 125

IntroductionAbdominal-pelvic mass, ascites and pleural effusion are suggestive of malignant metastatic ovarian cancer. This triad is also present in a rare benign condition called Meigs syndrome. Rarely this condition is associated with an increased CA 125 level.Case reportA 62-year-old woman with a history of abdominal pain underwent an ultrasound (US) examination and a chest X-ray. The imaging revealed the presence of a large pelvic mass and ascites with a monolateral pleural effusion and a high level of the tumor marker CA 125. The patient underwent a total abdominal hysterectomy, salpingoophorectomy, removal of the pelvic mass, pelvic lymphadenectomy and peritoneal biopsies. The histology showed an ovarian fibrothecoma.DiscussionThe US analysis according to international ovarian tumor analysis simple rules revealed “inconclusive results”; the logistic regression model LR2 and Adnex suggested a high risk of malignancy. The presence of ascites and the size of the lesion associated with a high level of CA 125 affected the correct assessment of the risk of malignancy, exposing the patient to overtreatmentConclusionsMeigs syndrome is characterized by the resolution of symptoms after surgical removal of the pelvic mass. However, it mimics the clinical picture of a malignant metastatic ovarian cancer. Clinicians have to exclude ovarian cancer and recognize the syndrome to reduce inappropriate procedures.

S2300 Henoch-Schönlein Purpura Induced Terminal Ileitis Mimicking Crohn's Disease

INTRODUCTION: Henoch-Schönlein purpura (HSP), also known as immunoglobulin A (IgA) vasculitis, is an acute generalized immune complex-mediated small-vessel vasculitis. It characteristically presents with palpable purpura on buttocks and lower extremities. Renal dysfunction, joint involvement and gastrointestinal (GI) symptoms are also frequently seen. Although gastrointestinal involvement is common, it primarily shows up in the form of nonspecific symptoms such as abdominal pain, nausea, vomiting, diarrhea or constipation. Terminal ileitis associated with HSP has rarely been reported in the medical literature. CASE DESCRIPTION/METHODS: A 22-year-old male presented with bilateral knee arthralgia, abdominal pain and intractable nausea and vomiting accompanied by a non-blanching erythematous coalescing maculopapular rash on the dorsal aspect of the feet and around the ankles bilaterally (Figure 1). CT (Figure 2) showed fold thickening of proximal loops of jejunum and wall thickening and luminal narrowing of the terminal ileum extending several centimeters proximally. Fluid-filled mildly dilated small bowel loops measuring up to 3 cm in diameter were visualized. Additionally, significant abdominal and pelvic ascites was noted. There was no evidence of bowel obstruction. During colonoscopy (Figure 3), granular, erythematous, ulcerated, hemorrhagic and ecchymotic mucosa was visible in the terminal ileum. There was blood in the terminal ileum and the colon. However, no discrete areas of bleeding were identified. These findings were consistent with moderate to severe active terminal ileitis. A skin biopsy was performed which confirmed the diagnosis of HSP. Methylprednisolone was commenced and the patient experienced relief in his GI symptoms. DISCUSSION: Although terminal ileitis is the pathognomonic hallmark of Crohn’s disease, it is important to consider alternative causes such as HSP in the differential diagnosis of ileitis indicative of Crohn’s disease. The resemblance between inflammatory lesions in the terminal ileum in HSP and those seen in Crohn’s disease hints at a potential pathophysiological link between the two disorders which is supported by an emerging body of literature.Figure 1.: Non-blanching erythematous coalescing maculopapular rash on the dorsal aspect of both feet and around the ankles.Figure 2.: CT Abdomen & Pelvis Coronal Section: small bowel inflammatory changes involving the jejunum and ileum.Figure 3.: Colonoscopy showing moderate to severe active terminal ileitis.

S2553 Endometriosis: A Rare Cause of Ascites

INTRODUCTION: Ascites is the pathological accumulation of fluid within the peritoneal cavity. These are mostly due to portal hypertension resulting from cirrhosis but there are non cirrhotic rarer causes of ascites. It is important to investigate the etiology of non-cirrhotic ascites as treatment of the underlying etiology can reverse it. CASE DESCRIPTION/METHODS: A 34-year-old female with history Cerebral Palsy presented to the clinic with 3 months of increasing abdominal distention. No associated jaundice, changes in urine color or constitutional symptoms. Examination revealed 10 cm reducible umbilical hernia along with abdominal fullness. No signs of portal hypertension or cirrhosis noted. Labs showed normal metabolic panel, blood counts and coagulation profile. Abdominal ultrasound revealed moderate to large ascites with nodular liver suggesting developing cirrhosis. She underwent paracentesis with removal of 5 liters of black-brown colored fluid showing many RBCs, 500 WBCs, Albumin of 3.5, Protein of 5.8, LDH of 978, SAAG of 0.6 and negative cytology. CT scan showed large abdominal and pelvic ascites, nodular liver and a 7 × 7 cm pelvic mass. MRI showed multiseptated pelvic collection with solid component in the right adnexal region. She underwent an exploratory laparoscopy with a right salpingo-oophorectomy and adnexal mass biopsy. Pathology showed ovarian fibroma with endometriosis. Follow up 3 months into the surgery, the patient was doing well and had no ascites. DISCUSSION: Cirrhosis is the most common cause of ascites. Ovarian fibroma and endometriosis are some of rare non cirrhotic causes as seen in this case. Ascites related to endometriosis was first described in 1954. A systematic review noted 63 cases with endometriosis related ascites between 1950 to 2010 who were mostly nulliparous women of African origin of ages 19 to 51 years. Diagnosis of endometriosis is usually delayed as it mimics gynecological malignancy and requires surgical exploration. Bilateral oopherectomy is the definite treatment. Here, right salpingo-oophorectomy was considered per patient preference. Ovarian fibromas are benign sex cord-stromal tumours seen in postmenopausal women which can present with ascites as a component of Meigs syndrome. Atypical causes such as these need to be considered especially in the young nulliparous females. Peritoneal fluid analysis and imaging may be misleading as they both can mimic malignancy, hence surgery is diagnostic. Therefore a broader differential is critical in evaluating ascites.Figure 1.: Initial CT scan of abdomen and pelvis with IV contrast showing soft tissue density structure within the anterior midline pelvis measures 6.5 × 7.5 × 7 cm.

S2490 Glycogenic Hepatopathy Masquerading as Acute Pancreatitis

INTRODUCTION: Glycogenic hepatopathy (GH) is underrecognized amongst clinicians.1,2 We present a case of GH clinically appearing at first as acute pancreatitis. CASE DESCRIPTION/METHODS: A 20-year-old female with a medical history of poorly controlled T1DM and prior episode of pancreatitis, presented with sharp epigastric pain worsened by eating. The patient was tachycardic to 115 bpm and physical exam revealed tenderness in the RUQ-epigastric region with negative Murphy's. Lab work was significant for WBC count 12,900/ μL, lipase 353 U/L, amylase 264 U/L, BHBA 3.02 mmol/L, HbA1C 13.5, ALT and AST 34 U/L and later AST 51 U/L, ALK 191, TG 162 mg/dL, and lactate 5.4 mmol/L which increased to 8.2 mmol/L. CT abdomen revealed hepatomegaly of approximately 24–25 cm craniocaudally, hepatic steatosis, trace pelvic ascites, and normal pancreas. Abdominal U/S showed an enlarged liver with diffuse increase in parenchymal echogenicity, consistent with steatosis, without any focal lesions. Mesenteric vascular doppler showed normal vasculature and flow. Hepatitis panel, iron panel, ANA, anti-smooth muscle antibody, and ceruloplasmin were negative. Liver biopsy showed preserved parenchyma without fibrosis, focal mild macrovesicular steatosis, and occasional glycogenated nuclei. The hepatocytes had increased swelling and cytoplasmic clearing, suggestive of glycogen deposition. PAS stain revealed abundant hepatocyte glycogen deposits which were not visible after diastase digestion. The histological findings are consistent with a GH diagnosis. DISCUSSION: GH, characterized by tender hepatomegaly with elevated liver enzymes in the setting of DM, exists within the Mauriac Syndrome spectrum, but lacks the syndrome's additional cushingoid features and poor growth. GH almost always occurs with T1DM and has slight female predominance. The pathobiology of GH may involve oscillation of glucose levels with poor insulin management leading to hepatocyte glucose trapping and glycogenosis.1 Biochemical findings include elevated HbA1c, AST greater than ALT, and elevated ALK.1,2 Increased amylase and lipase levels are reported as in our patient.3 DKA and lactic acidosis is common.4 Ascites has been reported.1 On CT the liver is hyperdense, unlike a hypodense liver of NAFLD.5 Definitive diagnosis is by findings of swollen hepatocytes with glycogen accumulation on biopsy, with limited or absent fatty change, inflammation, necrosis or fibrosis.1 Unlike NAFLD which may progress to fibrosis or cirrhosis, GH resolves with dysglycemia control.6,7Figure 1.: Benign liver parenchyma with focal mild macrovascular steatosis. Many hepatocytes have increased swelling and cytoplasmic clearing.Figure 2.: Occasional glycogenated nuclei are seen, as indicated by the black arrow.Figure 3.: A PAS stain highlights abundant glycogen in the hepatocytes, as evidenced by the magenta staining, but is not seen in the PASD stain (PAS stain after diastase pretreatment).