A 14-year-old girl presented to the emergency department with complaints of abdominal pain, discomfort, and distention for at least 6 months. Past surgical history was significant for adenoidectomy at the age of 2 years. There is no other significant medical history. She is not on any medications. She is allergic to albuterol. Last cycle was 2 months ago. She denies ever having a pelvic examination or Pap smear. The patient denies both being sexually active and using illegal drugs, tobacco, and alcohol. She lives with her mother, who is present at this visit. Her family history is noncontributory. The vital signs were as follows: temperature = 97.7 °F, pulse = 79, respirations = 16, blood pressure = 112/70, and weight = 71 kg. She was alert and oriented with moderate distress. She was leaning forward with her hands on her knees with the inability to stand straight up. During her examination, abdominal, costal, and low back pain were elicited. Her skin was warm, dry, and intact. There was no palpable lymphadenopathy in her neck, axilla, or groin regions. Her lungs were clear with the bases diminished bilaterally upon auscultation. She was unable to take a deep breath because of pain. Her heart was regular; however, slight tachycardia was noted. Her abdomen was firm, moderately tender with normoactive bowel sounds. The external genitalia appeared normal. A normal-appearing cervix and a uterus of normal size were shown. However, there was fullness in her right adnexa without palpation of a discreet mass. (Figure 1)
WHAT IS YOUR DIAGNOSIS?
- Ovarian cyst
- Inflammatory bowel disease
THE DIAGNOSIS IS:
Right ovarian cyst.
The patient had been seen multiple times in a rural clinic with complaints of abdominal discomfort for more than 18 months and abdominal distension for 6 months. She was diagnosed with weight gain and instructed to exercise and follow up in clinic. As her abdomen grew increasingly large, her symptoms became more symptomatic with pain, inability to stand, and inability to take a deep breath or eat a full meal. Her symptoms increased rapidly over 3 days, and she arrived at the emergency room for treatment. She did not have any imaging at the rural clinic. Patient imaging revealed a large cystic abdominal mass. The mass appeared to arise from the right ovary and measured 35 × 28 cm. The uterus appeared normal, and the left ovary was not visible.
RESOLUTION OF THE CASE AND PATIENT OUTCOME
Surgical intervention was determined as the appropriate intervention for an exploration of the pelvic mass. The cyst was drained and removed through a small, 4- to 5-cm incision. Eight liters of fluid was drained from the cyst before it was removed. The surgeon removed the cyst, right fallopian tube, and ovary.
Pathology specimens were collected during surgery.
A 25 × 19 × 3 cm specimen was sent to pathology for evaluation during surgery labeled “right tube and ovary frozen section.” Initial examination during surgery revealed a mucinous cyst. Pathology called initial results to operating room before surgical close. Results after fixation reveal a mucinous cystadenoma of the ovary and benign fallopian tube.
A 30-ml fresh body-fluid specimen was sent to pathology labeled “ascites.” The results were benign mesothelial cells, neutrophils, and macrophages.
The patient had no surgical complications (Figure 2). Because of the distance from her home, she remained an inpatient for 3 days. Her pain was tolerable, and she had an uneventful recovery. She was counseled for her anxiety for her return to home as her schoolmates believed her to be pregnant and “coming to town to for labor.”
INFORMATION ABOUT THE DIAGNOSIS
Cysts in adolescents vary from simple to complex. The simple cysts are most commonly follicular cysts. Follicular cysts are follicles that do not fully mature and rupture during the menstrual cycle. If they do not rupture, they can grow into larger neoplasms. These cysts are usually asymptomatic and resolve spontaneously (Laufer, 2017). Corpus luteum cysts are cysts that occur after a follicle ruptures but do not dissolve. These cysts can grow quite large and have a risk of intraperitoneal hemorrhage; however, even if bleeding occurs, observation is the recommended therapy (Laufer, 2017). Mucinous cystadenomas are one of the most common benign ovarian masses and can grow to be extremely large. Mucinous cystadenomas have mucus cells lining the thin walls and collect mucin in their cytoplasm (Hochberg & Hoffman, 2016). Torsion is a concern with ovarian cysts. Ovarian torsion symptoms include sudden unilateral pain with nausea and/or vomiting. Ovarian torsion is an emergency as there is decreased blood flow resulting in tissue loss (Biggs & Marks, 2016). When surgical intervention for the neoplasm is required, the method should be as minimally invasive as possible and attempt to protect the ovaries to prevent reproductive problems later (Suer Timur et al., 2015).
Biggs W. S., & Marks S. T. (2016). Diagnosis and management of adnexal masses. American Family Physician
, 93(8), 676–681.
Suer Timur E., Incebiyik A., Camuzcuoglu A., Hilali N. G., Camuzcuoglu H., & Vural M. (2015). Adnexal mass requiring surgical intervention in adolescent girls. European Journal of General Medicine
, 12(3), 239–243. doi:10.15197/sabad.1.12.50