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Acta Radiologica

ISSN: 0284-1851 (Print) 1600-0455 (Online) Journal homepage: http://www.tandfonline.com/loi/iard20

Entrapped ovarian cyst

E. Hederström & L. Forsberg

To cite this article: E. Hederström & L. Forsberg (1990) Entrapped ovarian cyst, Acta Radiologica,
31:3, 285-286

To link to this article: https://doi.org/10.1080/02841859009171992

Published online: 04 Jan 2010.

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Acra Radiologica 31 (1990) Fasc. 3

FROM THE DEPARTMENTS OF DIAGNOSTIC RADIOLOGY, UNIVERSITY HOSPITAL, S-221 85 LUND, SWEDEN.

ENTRAPPED OVARIAN CYST

An unsual case of persistent abdominal pain

E. HEDERSTROM
and L. FORSBERC

Abstract scars (in total 14 operations), following a hysterectomy in 1983.


Recurrent abdominal pain in the left fossa often mimicking at- Recurrent episodes of low abdominal pain of interval character
mostly located to the left fossa occurred between 1984 and 1988
tacks of subileus is described in a woman aged 48 with extensive
adhesions caused by multiple surgical procedures. Repeated examin- and were clinically suggested to be attacks of subileus. Conventional
ations with conventional abdominal radiography and barium meals abdominal radiography was performed on 5 occasions. At 3 exami-
nations the clinical hypothesis of mechanical obstruction could not
were negative with regard to mechanical intestinal obstruction. A
cystic lesion varying in size from 2 to 8 cm in diameter was seen be verified, whilst at one, dilatation of the stomach was seen and
adjacent to the left ovary on repeat US examinations and also on the fifth was consistent with partial obstruction although a follow
CT. Pain episodes were sometimes correlated to increasing size of through was normal. In addition, no adhesions, strictures or other
pathology could be observed in the small intestines in 2 elective
the lesion which was finally thought to be either a peritoneal in-
clusion cyst (fluid trapped between pelvic adhesions) or, as was upper gastro-intestinal barium examinations.
finally confirmed at surgery, a true ovarian cyst (corpus luteum The patient had 17 US and 2 computed tomography (CT) examin-
cyst) similarly trapped. ations during a period of 4 years. On the first US in 1984 a left-
sided, simple ‘ovarian cyst’ (diameter 2 cm) was accidentally dis-
Key words: Pelvis, CT; --. cyst; --, US studies. covered, but on a following US both ovaries could be located and
had a normal appearance. Increasing pain and a palpable lesion in
the left fossa 5 months later motivated a CT where an 8 x 4 x 4 . 5
Follicular or corpus luteum cysts are frequent in post cm fluid collection was seen in the left pelvis. At a fine needle
pubertal women. Slight abdominal pain is often observed puncture 25 ml of clear, yellow fluid was aspirated.
Between October 1986 and April 1988 15 US studies and one CT
after cyst rupture and a small amount of free fluid in the were performed showing a wide range of findings from no fluid to
pouch of Douglas can often be seen in these patients. The a cystic lesion varying between 3 and 6 cm in diameter, always
condition is usually self-limited and surgical treatment is located adjacent to the left ovary (Figs I , 2). Fine needle puncture
seldom required. was repeated twice, rendering 3 and 15 ml, respectively. No malig-
In patients with peritoneal adhesions fluid emanating nant cells were ever discovered, only fragments of inflammatory
cells and debris.
from a ruptured cyst may, however, be trapped, forming The degree of urgent pain was parallel to an observed growth of
so called peritoneal inclusion cysts. This entity, to which the lesion on 3 occasions though slight pain was noted also when
attention was first drawn within the discipline of pathology, no fluid was present. The intestines of the pelvis differed with regard
is little known in radiologic literature where the ultrasono- to fluid content but were never dilated on US to a degree indicating
a mechanical obstruction.
graphic (US) features of 4 cases have recently been described The patient was eventually operated upon in 1988 with a left
(3). In view of the hitherto few reported cases of this some- oophorectomy, when a corpus luteum cyst extensively surrounded
what vaguely defined clinical condition, we present a case by peritoneal adhesions was found. Considerable but not complete
report which has been challenging from the diagnostic point pain relief followed postoperatively and the patient has had one
further US examination (normal finding) after that.
of view.
Discussion
Case report Extensive pelvic adhesions in women with active ovaries
have been described as carrying an increased risk for devel-
A 48-year-old woman had been subjected to multiple abdominal
surgery, e.g. for intestinal adhesions and hernia of the operation Accepted for publication 17 October 1989.

285
286 E. HEDERSTROM AND L. FORSBERG

Fig. 1. Cyst of small size dorsal to the iliac vessels on US. a = iliac Fig. 2. Increasing size of the cyst. Abbreviations as in Fig. 1
artery, v = iliac vein, c = cyst.

opment of peritoneal inclusion cysts which arise when the can only be reached by new imaging modalities like US or
fluid produced by normally functioning ovaries gets trapped CT. In these patients it is also tempting to blame recurrent
between pelvic adhesions (3, 4).The peritoneum may after episodes of pain on attacks of subileus and we believe that
previous diseases have an impaired ability to absorb the mechanical intestinal obstruction must first be excluded
produced fluid. The inclusion cysts are adherent to the since the clinical symptoms unfortunately mimick the pain
ovarian surface or contiguous to the adnexa. It is usually created by an entrapped cyst. Also in this respect, US is
impossible to differentiate them by radiologic methods from useful for differential diagnosis or as a complement to ab-
true ovarian cysts or primary parovarian cysts (1, 2), but dominal radiography since fluid-filled intestinal loops
this can be achieved by histopathologic examination ( 5 ) . In usually are well seen.
the presence of a cystic lesion other differential diagnoses Awareness of this pain-producing condition caused by a
should also be considered, e.g. ovarian neoplasms or lymph- combination of ovarian cysts (different types) and pelvic
angioma (3). adhesions may, however, be helpful in the presence of nega-
Our patient had been subjected repeatedly to pelvic sur- tive abdominal radiography and follow through examin-
gery, like most others in previously reported series (in total ations when the addition of US and CT can be recom-
9 out of 10; 2 series) (3, 5 ) , and had tight adhesions sur- mended.
rounding the left ovary. The clinical setting, including diag-
nostic difficulties, was well comparable to that encountered Request for reprints: Dr Esbjorn Hederstrom, Department of
in other patients. Diagnostic Radiology, University Hospital, S-221 85 Lund, Sweden.
The appearance and location of the mass also changed
somewhat during the observation period, with regard to its
relation to the iliac vessels, being most often located lateral REFERENCES
and dorsal to the vessels. For some time, the possibility of
1. ALPERNM. B.. SANDLER
M. A. and MADRAZO
B. L.: Sonogra-
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from episodes of stalk torsion, was discussed. J. Roentgenol. 143 (1984), 157.
The medical record of this patient is, however, suggestive. 2. ATHEYP. A. and COOPER N. B.: Sonographic features of par-
Pelvic adhesions, inflammatory diseases or endometriosis ovarian cysts. Amer. J. Roentgenol. 144 (1985), 83.
3. HOFFER F. A,, KOZAKEWICH H., COLODNY A. and GOLDSTEIN
seem to be a prerequisite for developing peritoneal inclusion
D.: Peritoneal inclusion cysts. Ovarian fluid in peritoneal ad-
cysts. The mechanism of ‘entrappment’ by adhesions caus- hesions. Radiology 169 (1988), 189.
ing pain may logically be applicable not only to the fluid 4. KONINCKX P. R., RENAER M. and BROSENSI. A.: Origin of
forming peritoneal inclusion cysts but also to true cysts, e.g. peritoneal fluid in women. An ovarian exudation product. Brit.
corpus luteum cysts varying in size as in our patient. J. Obstet. Gynaecol. 87 (1980), 177.
5. MCFADDEN D. E. and CLEMENT P. B.: Peritoneal inclusion
The entity of peritoneal inclusion cysts and the suggested cysts with mural mesothelial proliferation. A clinicopathol-
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