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A Tubo-Ovarian Abscess That Perforates the Sigmoid Colon
Image of the Month A Tubo-Ovarian Abscess That Perforates the Sigmoid Colon RAVI K. PRAKASH,* NIRAV SHAH,‡ and D. ROY FERGUSON‡ *Department of Internal Medicine, ‡Department of Gastroenterology, Metro Health Medical Center, Cleveland, Ohio
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here are a number of unusual polypoid lesions that are encountered during colonoscopy (eg, colitis cystica profunda, pneumatosis cystoids intestinalis, metastatic lesions, lymphoid polyps, colonic lipomas, carcinoids, leiomyomas, and so forth). We report a rare presentation for a polypoid lesion. A 22-year-old white woman, G2P1A1 (Gravida 2, Para 1, Abortion 1) with no medical comorbidities, was referred for management of a left adnexal mass along with an increased cancer antigen 125 level at 347 (normal ⬍35) and positive stool occult blood. She presented with a 2-month history of abdominal bloating, indigestion, and night sweats. She denied any history of sexually transmitted disease or use of intrauterine contraceptive device. Examination revealed tenderness in the left-lower quadrant of the abdomen. A urine pregnancy test was negative. A computerized tomographic scan of pelvis confirmed the presence of a unilocular cystic mass in the left pelvic adnexa measuring 6.5 cm in diameter, consistent with a left ovarian cyst with an adjacent mass measuring 5.8 ⫻ 4.8 ⫻ 5.4 cm. The white arrow shows the site of erosion of the abscess into the adjacent edematous bowel wall (Figure A). Colonoscopy showed a polypoid lesion at 22 cm that was 6 mm in diameter. On washing, the lesion disintegrated to a structure having fimbriaelike extrusions as shown in Figure B. At an oblique view the lip of the colon was visible at the base of the lesion and it appeared extraintestinal eroding into the colon. Biopsy of the polypoid lesion showed fibrovascular tissue with mixed inflammation on pathologic examination. Subsequently, the patient underwent a left salpingo-oophorectomy, sigmoid colectomy, and primary colonic anastomosis. Pathology confirmed the diagnosis of a tubo-ovarian abscess along with transmural colonic wall inflammation at the site of entry of the abscess to form a polypoid lesion (Figure C). The patient had an uneventful recovery.
Discussion A tubo-ovarian abscess is one of the more severe complications of pelvic inflammatory disease.1 It is formed by an inflammatory mass involving the fallopian tube, ovary, and often surrounding structures. This tubo-ovarian abscess perforated into the sigmoid colon and appeared as a polypoid mass on colonoscopy. There are reports of colonic involvement with perforation in other gynecologic pathologies that include endometriosis,2 pelvic actinomycosis, and ovarian malignancies including pseudomyxoma peritonei.3 The endoscopist should be aware of the broad nature of presentation of polypoid lesions. References 1. Sweet RL. Anaerobic-aerobic pelvic infection and pelvic abscess. In: Sweet RL, Gibbs RS, eds. Infectious diseases of the female genital tract. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:189 –206. 2. Viscido A, Aratari A, Pimpo M, et al. An unusual treatment for a colonic polyp. Gut 2004;53:1000 –1019. 3. Goldstein PJ, Cabanas J. Pseudomyxoma peritonei from the colonic polyps. Eur J Surg Oncol 2006;32:764 –766.
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2009.11.008 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:xxvi
T
here are a number of unusual polypoid lesions that are encountered during colonoscopy (eg, colitis cystica profunda, pneumatosis cystoids intestinalis, metastatic lesions, lymphoid polyps, colonic lipomas, carcinoids, leiomyomas, and so forth). We report a rare presentation for a polypoid lesion. A 22-year-old white woman, G2P1A1 (Gravida 2, Para 1, Abortion 1) with no medical comorbidities, was referred for management of a left adnexal mass along with an increased cancer antigen 125 level at 347 (normal ⬍35) and positive stool occult blood. She presented with a 2-month history of abdominal bloating, indigestion, and night sweats. She denied any history of sexually transmitted disease or use of intrauterine contraceptive device. Examination revealed tenderness in the left-lower quadrant of the abdomen. A urine pregnancy test was negative. A computerized tomographic scan of pelvis confirmed the presence of a unilocular cystic mass in the left pelvic adnexa measuring 6.5 cm in diameter, consistent with a left ovarian cyst with an adjacent mass measuring 5.8 ⫻ 4.8 ⫻ 5.4 cm. The white arrow shows the site of erosion of the abscess into the adjacent edematous bowel wall (Figure A). Colonoscopy showed a polypoid lesion at 22 cm that was 6 mm in diameter. On washing, the lesion disintegrated to a structure having fimbriaelike extrusions as shown in Figure B. At an oblique view the lip of the colon was visible at the base of the lesion and it appeared extraintestinal eroding into the colon. Biopsy of the polypoid lesion showed fibrovascular tissue with mixed inflammation on pathologic examination. Subsequently, the patient underwent a left salpingo-oophorectomy, sigmoid colectomy, and primary colonic anastomosis. Pathology confirmed the diagnosis of a tubo-ovarian abscess along with transmural colonic wall inflammation at the site of entry of the abscess to form a polypoid lesion (Figure C). The patient had an uneventful recovery.
Discussion A tubo-ovarian abscess is one of the more severe complications of pelvic inflammatory disease.1 It is formed by an inflammatory mass involving the fallopian tube, ovary, and often surrounding structures. This tubo-ovarian abscess perforated into the sigmoid colon and appeared as a polypoid mass on colonoscopy. There are reports of colonic involvement with perforation in other gynecologic pathologies that include endometriosis,2 pelvic actinomycosis, and ovarian malignancies including pseudomyxoma peritonei.3 The endoscopist should be aware of the broad nature of presentation of polypoid lesions. References 1. Sweet RL. Anaerobic-aerobic pelvic infection and pelvic abscess. In: Sweet RL, Gibbs RS, eds. Infectious diseases of the female genital tract. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:189 –206. 2. Viscido A, Aratari A, Pimpo M, et al. An unusual treatment for a colonic polyp. Gut 2004;53:1000 –1019. 3. Goldstein PJ, Cabanas J. Pseudomyxoma peritonei from the colonic polyps. Eur J Surg Oncol 2006;32:764 –766.
Conflicts of interest The authors disclose no conflicts. © 2010 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2009.11.008 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:xxvi