Twisted Huge Ovarian Cyst: The Clinical Lessons

Case Report

Austin J Clin Case Rep. 2015;2(3): 1074.

Twisted Huge Ovarian Cyst: The Clinical Lessons

Muwaffaq Mezeil Telfah*

Department of Surgery, College of Medicine, University of Mosul, Iraq

*Corresponding author: Muwaffaq Mezeil Telfah, Department of Surgery, College of Medicine, University of Mosul, Iraq

Received: September 13, 2014; Accepted: June 04, 2015; Published: June 06, 2015


A 30 year old woman presented to the surgical outpatient clinic with painless abdominal distension for the last six months. The patient had previous visits to the general practitioner who misinterpreted the case as a truncal obesity and reassurance was given. The basic clinical examination revealed an encysted intra-abdominal fluid occupying most of abdominal cavity. This clinical suspicion proved by imaging studies (Ultrasound and Computed Tomography) as encysted intra-abdominal fluid of unknown aetiology. The patient was given an elective appointment on the next available list. Meanwhile, she developed mild lower abdominal pain treated conservatively and advised to wait for surgery. On the day of surgery, she had normal vital signs and little abdominal physical signs. Per-operatively, a huge twisted right ovarian cystic lesion found treated by tubooophorectomy and delivered intact without spillage via long lower midline incision. The histopathology report revealed mucinous cystadenoma of ovary. The patient had smooth postoperative recovery and was well and pain free during the follow-up.

This case highlights the difficulties that may be encountered in the management of patients with abdominal distension due to encysted intra-abdominal fluid including potential misdiagnosis of the abdominal distension as an obesity. Also, It is a reminder about using basic clinical skills in diagnosing common disorders and taking all the necessary precautions to deal with suspicious intra-abdominal pathology.


The presentations of intra-abdominal pathology are variable and represent a diagnostic challenge for physician [1]. However, back to basic principle is the gold standard to reveal the disease process. Basic clinical and operative skills usually lead to the diagnosis and ensure safe surgery. Every physician must be equipped with the clinical skills to detect intra-abdominal fluid collection and differentiate between encysted and free fluid utilising dull percussion notes, transmitted thrill and shifting dullness clinical tests [2].Occasionally, patients present to outpatient clinic with increasing abdominal distension which may be misinterpreted as a case of obesity. In such cases, all of aetiologies of abdominal distension namely the 6 Fs (Fetus, Flatus, Faeces, Fat, Fluid: free/encysted, large solid tumour e.g. Fibroid) should be considered in the differential diagnosis as a basic clinical knowledge [2]. The ovarian pathology is a common underlying cause for such clinical presentation (encysted intra-abdominal fluid) [3]. Ovarian cysts are a common cause of surgical procedures and hospitalizations among women worldwide. It has been reported that 5% to 10% of women will undergo surgery for an adnexal mass [1, 3]. This pathology should always be kept in mind during the assessment of women with abdominal distension at child bearing age. These pathologies should be treated urgently (preferably at the same admission) to avoid the development of serious complications such as twisting, haemorrhage and rupture [4]. The diagnosis of patients with encysted intra-abdominal fluid may be delayed and only diagnosed after surgical exploration for a vague abdominal mass without any clues to the surgeon whether it is benign or malignant mass.

During surgery, all surgeons should be vigilant and follow the standards of safe surgical skills in dealing with suspicious intraabdominal pathology especially when the pre-operative diagnosis is suspicious and the pathology is cystic. Accordingly, surgeons should be aware of more serious than simple pathology when encounter a huge cystic intra-abdominal pathology. It is important to remove the whole lesion intact without attempt of aspiration to prevent dissemination of fluid and implanting a secondary pathology. The reported case had a difficulty in establishing the initial diagnosis and developed serious complication while on the waiting list. Also, the case required a careful planning for safe surgical treatment.

Case Presentation

A recently married 30 year old woman presented to the outpatient clinic with abdominal distension for six months duration. She was well before marriage. She developed the abdominal distension gradually and it was completely painless. The patient had previous visits to her general practitioner about the condition but she was not investigated well and only received reassurance. She had a recent disturbance in her menstrual cycle (oligomenorrhea to menorrhagia) and had a missed period of three weeks at the time of presentation. Review of all other systems was normal and there were no relevant medical or surgical history. There was no similar cases in the family. Physical examination performed together with an input sought from a gynaecologist. The general examination was normal apart from hirsutism noted on the chin, body mass index (BMI) of 24.9 kg/m2 and hemodynamically stable. Local abdominal examination revealed a symmetrical gross abdominal distension (Figure 1,2), soft, dull percussion notes throughout the abdomen. A positive fluid thrill and negative shifting dullness suggesting encysted intra-abdominal fluid. There was no organomegaly. The bowel sound are positive but distant. Per-vaginal examination done with positive cervical excitation test.