Significant Free Fluid Research Articles

A Curious Case of Misapprehension – Dermoid Cyst Masquerading as a Ruptured Ectopic Pregnancy

We discuss the case of a 26-year-old woman who presented with pelvic pain and recent onset vaginal bleeding in early pregnancy. Transvaginal USS identified significant free fluid in the pelvis associated with a right adnexal mass and an empty uterus. A ruptured ectopic pregnancy was suspected, and the patient was taken to theatre for an emergency laparoscopy. Paradoxically, the procedure found no signs of intra-abdominal blood loss. Instead, a large, unruptured 20cm ovarian cyst filled the right adnexa and Pouch Of Douglas (POD), extending posteriorly towards the pelvic brim. It was a right Ovarian, Dermoid cyst. Surprisingly, the dilemma is not unique. We identified similar reports in the literature where unsuspected ovarian pathology is discovered at the time of early pregnancy surveillance, often masquerading as an acute complication of early pregnancy. In this report, the patient went on to have a spontaneous miscarriage, and the cyst was later removed by mini- laparotomy. We present this case as an opportunity to highlight the epidemiology of adnexal pathology presenting for the first time in early pregnancy and to help broaden clinical suspicion when considering potential diagnoses at the time of presentation.

Traumatic Small Bowel Injury: A Diagnosis Challenge

Traumatic small bowel injury is rare complication following a blunt abdominal trauma. We encountered a case of small bowel injury following a motor vehicle accident that was initially missed during the first presentation due to unremarkable findings in examination. Patient re-presented five days later with bowel ischaemia and was managed accordingly. It is a challenge in diagnosing the injury due to its vague presentation. The usage of Focused Assessment with Sonography for Trauma (FAST) scan as a screening tool in Emergency Department to pick up intra-abdominal injury do have limitations especially in diagnosing small bowel perforation post blunt abdominal trauma. The early phase of small bowel injury post blunt abdominal trauma rarely produces significant free fluid during the FAST scan. It is paramount for the emergency doctors to have a high level of suspicion in high risk cases to provide early supportive treatment and early referral to surgical team. If left undiagnosed bowel ischaemia may lead to catastrophic complication affecting the patient’s morbidity and mortality. In conclusion, each case should be managed and risk stratify individually. Computed tomography abdomen is found to be more superior in detecting bowel injuries, hence, and investigation of choice compared to bedside ultrasonograpy in cases with high level of suspicaion.

Chocolate Endometrial Cyst: A Case Report

Introduction: Chocolate cysts are noncancerous, fluid-filled cysts that typically form deep within the ovaries. They get their name from their brown, tar-like appearance, looking something like melted chocolate. They're also called ovarian endometriomas [1].
 Case Presentation: The authors report an unusual case of chocolate endometrial cyst. During history collection it found that patient develop a severe pain at midnight, after all the investigation the ultrasonography they diagnosed probe tenderness in RIF. Significant free fluid in abdominal cavity. Well circumscribed mix echoic mass lesion seen in hypogastric region more in right paraumbilical region with eccentrically placed small tubular structure visualized. Mass lesion of size 110mm×110mm. USG guided tapping done, the ascitic fluid smears shows fresh RBC’s and other blood cells entrapped in fibrin clot. Background is haemorrhagic and malignant cells are absent. Abdominal surgery was done and chocolate cyst was removed and sent to histopathology for further investigations.
 Conclusion: In this study, author mainly focus on expert surgical management and excellent nursing care which leads to fast recovery of patient. After conversation with patient her response was positive and after nursing management and treatment she was discharged without any postoperative complications and satisfaction of recovery.

Resolution of sclerosing encapsulating peritonitis in a young dog

An eight-month-old Labrador retriever presented with abdominal effusion. Abdominal ultrasonography revealed significant free fluid and a linear hyperechoic band surrounding the abdominal organs. CT showed the gastrointestinal organs to be...

Multiple Faces of the Same Pathology

Ectopic pregnancy is defined as an extrauterine pregnancy. We report three cases where the ectopic pregnancies were implanted in different sites. The first case was a 28-year-old in her second pregnancy at 9 weeks gestation. She presented with painless vaginal bleeding. Ultrasound showed unruptured cornual pregnancy with hCG level of 7456mIU/ml. A single dose of 75mg IM methorexate was given and she responded well with significant reduction of hCG level. The second case, a 26-year-old gravida 5 para 2+2, with 2 previous ectopic pregnancies and bilateral salpingectomy, conceived via in-vitro fertilization (IVF). She presented with acute abdomen and one episode of syncope at 8 weeks 4 days gestation. Laparotomy showed ruptured ectopic pregnancy at the left tubal stump requiring a left salpingectomy. The third case was a 26-year-old, gravida 5 para 2+2, with two previous vaginal deliveries and two previous first trimester miscarriages. Her menses was irregular since she took injectable progestin. She presented to the emergency department with sudden onset of lower abdomen pain. Urine pregnancy test was positive. Ultrasound showed empty uterus, no adnexal mass but there was significant free fluid in the cul-de-sac. During laparoscopy, a ruptured ovarian pregnancy was diagnosed and salpingo-oophorectomy performed. There was no significant risk factor contributing to ectopic pregnancy identified in the first and third case. In the second case, despite previous bilateral salpingectomy, the patient still had ectopic pregnancy in the left fallopian tube remnant.

Filling Index Score of Remplissage (FISOR): a useful measurement tool to evaluate structural outcome after remplissage

The purpose of this study was to evaluate and to grade the extent of filling into the Hill-Sachs lesion quantitatively by use of magnetic resonance arthrography after an arthroscopic remplissage procedure. The current study enrolled 23 patients who underwent arthroscopic Bankart repair with a remplissage procedure for a large or engaging Hill-Sachs lesion confirmed by arthroscopic findings. The postoperative filling index was classified into 5 categories by axial and sagittal views of T2-weighted images on magnetic resonance arthrography: complete filling (4 points); partial filling with minor defect (3 points); partial filling with major defect (2 points); minimal filling with significant free fluid level (1 point); and filling failure with dehiscence (0 point). Filling Index Score of Remplissage (FISOR) was also calculated from the total sum of points in the axial and sagittal planes and classified into 5 grades. The FISOR was 8 points in 13 patients, 7 points in 2 patients, 6 points in 3 patients, 5 points in 1 patient, 4 points in 1 patient, 3 points in 1 patient, 2 points in 1 patient, and 0 point in 1 patient. According to the FISOR grades, these results were recorded as excellent in 15 patients (65.2%), good in 4 patients (17.4%), fair in 2 patients (8.7%), poor in 1 patient (4.3%), and no evidence of filling in 1 patient (4.3%). The FISOR would be a useful measurement tool for the evaluation of structural outcomes after the remplissage procedure.

Second trimester pregnancy in a rudimentary uterine horn

Sir, We wish to call attention to the case of a 34-year-old woman who presented to the emergency clinic with severe abdominal pain. She believed herself to be 13 weeks pregnant. The pregnancy had so far been uneventful. She had not attended the antenatal care program and had undergone no ultrasound examinations during her pregnancy. Earlier on the same day her general practitioner had reported ‘size of uterus according to gestation’. She had previously given birth to three children, the first child by cesarean section in week 29 and the second and third child by term vaginal delivery. On examination she was awake and conscious, but pale and in severe pain. Blood pressure was 98/65 mmHg and pulse 73 bpm. The hemoglobin was 6.0 g/l and serum-hCG 22,252 iu/l. There were signs of peritoneal irritation in the left iliac fossa. Transvaginal ultrasound revealed an empty uterus and a small hyperechoic mass close by the left ovary. The right ovary appeared normal and no significant free fluid was found in the Pouch of Douglas. An ectopic pregnancy was suspected. An emergency laparotomy was performed revealing massive hemoperitoneum. A ruptured rudimentary horn containing the placenta was found on the left side of the uterus. The fetus was found floating in the abdominal cavity. It was estimated to be of 16 weeks of gestation according to crown-heel length. There were no visible malformations. An excision of the ruptured uterine horn along with the placenta and a left salpingectomy was performed. Measured blood loss was 4.8 l and blood transfusions and fresh frozen plasma were given. The woman recovered without complications and was discharged 4 days later. This case illustrates an extremely rare and potentially life-threatening condition that remains a diagnostic challenge. It is to the best of our knowledge the first reported case of a ruptured uterine horn pregnancy following two term vaginal deliveries and a cesarean section. Congenital uterine malformations occur in 1:200 to 1:600 women (1). The presence of a rudimentary uterine horn is a result of abnormal development of one of the Müllerian ducts. In a review of 568 cases of rudimentary uterine horn pregnancies a rupture rate of 50.1% was found with 80% occurring before the third trimester (2). The maternal mortality rate fell from 23% in the 1920s to less than 0.5% more recently. This woman had not previously been diagnosed with a uterine malformation. In the operation notes of the cesarean section ‘a fibroma-like structure at the origin of the left salpinx’ was described, which is likely to have been the rudimentary horn. Women with uterine malformations have a higher risk of obstetric complications, including preterm labor (3). Prior knowledge of this condition would thus be valuable, but the sensitivity of ultrasound for diagnosing rudimentary horn pregnancies is only 29% (4). There are a few reports of rudimentary horn pregnancies proceeding to term, but immediate surgery is the standard treatment when the diagnosis is made.

Decidualized ovarian endometriosis in pregnancy: a challenging diagnostic entity

The hormonal milieu that characterizes pregnancy may determine profound modifications of ovarian endometriomas leading to lesions mimicking malignancy. In this study, we report on our experience and perform a review of the literature on this issue. Data from women evaluated at our referral center for prenatal diagnosis were reviewed in order to identify those who were detected with an ovarian endometrioma in pregnancy mimicking malignancy. A review of the literature on this issue (1990-2008) was also performed, using the PubMed database. Three cases were identified at our center. The literature reports on a further 19 cases (11 studies). Sonographic and color Doppler examination consistently documented rapidly growing and abundantly vascularized intracystic excrescences. Conversely, the presence of septations or significant free fluid was never reported. The vast majority of cases underwent surgical removal. Interestingly, in our experience, in a woman who declined surgery and had spontaneous miscarriage at 10 weeks' gestation, the sonographic examination performed 6 weeks after dilatation and curettage revealed an unremarkable typical endometrioma, thus suggesting that it is a transitory transformation. Pregnancy-related modifications of an ovarian endometrioma leading to the rapid development of vascularized intracystic excrescences are an uncommon but possible event. An expectant management and serial monitoring should first be envisaged in these cases provided that other features of malignancy, such as septations or free fluid, are absent.

From the RSNA refresher courses: focused abdominal US for trauma.

Focused abdominal ultrasonography (US) has been introduced in Europe as a method to evaluate blunt abdominal trauma. The main focus of the examination is detection of free fluid in the abdomen secondary to injury of the abdominal organs. The examination takes only a few minutes to perform. In the authors' experience, trauma patients in unstable condition and in whom significant free fluid is detected are immediately taken to the operating room for surgical exploration without undergoing computed tomographic (CT) correlation. The authors have also used US to identify the specific site of organ injury. Injuries to solid organs such as the liver, spleen, and kidney that are identified with US usually appear heterogeneous or hyperechoic. A hematoma surrounding the injured organ may appear echogenic or hypoechoic. However, pitfalls of focused abdominal US for trauma include failure to show contained solid-organ injuries; injuries to the diaphragm, pancreas, and adrenal gland; and some bowel injuries. Thus, negative findings at US do not exclude an intraperitoneal injury, and close clinical observation or CT is warranted.