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Fatal perforation of endometriotic colon
Inr J Gynecol Obstet, 1992, 37: 301-303 International Federation of Gynecology
301 and Obstetrics
Letters to the Editor Fatal perforation of endometriotic colon To the Editor
December 20th, 1991
Perforation of the bowel secondary to endometriosis is rare with only three cases reported [1,4]. We describe a patient with vaginal agenesiscervical atresia, who had a fatal septic peritonitis secondary to perforation of endometriotic colon. The patient, a 19-year-old woman, was admitted because of primary amenorrhea, recurrent pelvicabdominal pain, low-back pain, constipation, and abdominal mass. Laparoscopy done 2 years earlier, revealed severe endometriosis. Reconstructive vaginal-uterine surgery was advised then, but was declined because of social-cultural reasons, she received medroxy progesterone acetate (proVera) instead. On admission, clinical examination and imaging studies revealed a large pelvicabdominal mass which was partially cystic. IVP manifested mild bilateral hydroureters. Laboratory investigations were within normal limits. The need to establish a conduit for menstrual egress was stressed, but again declined. The family consented for exploratory laparotomy only, leaving the final decision of extirpative or reconstructive surgery until after marriage. Laparotomy revealed a hematometra, bilateral hematosalpinx, multiple chocolate cysts, and upper sigmoid colon endometrioma. Evacuation of chocolate cysts was performed with biopsies documenting endometriosis. Postoperative recovery was uneventful and the patient was discharged on day 5. She took provera 20 mg p.o. daily. Six weeks later she was readmitted with symptoms and signs of acute abdomen. An emergency laparotomy revealed a massive fecal contamination seeping through a 3 x 2 cm perforation involving a sigmoid colon endometrioma. Surgery was complicated by intraoperative cardiac arrest Keywords: Peritonitis.
Vaginal
agenesis;
Cervical
atresia;
Endometriosis;
but normal cardiac activity resumed after 4 min of resuscitation. Transverse colostomy was performed and multiple Jackson-Pratt (Heyer Schulte Co., Goletta, California, USA) drains were placed in the pelvis and abdomen. She developed septic shock, irreversible disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS) and expired on postoperative day 8. In a comprehensive literature survey of cervical atresia, Jacob and Griffin [3] concluded that although surgical intervention is mandatory to prevent hematometra, disabling pelvic pain, and unabated endometriosis, hysterectomy remained the definitive therapeutic modality. Geary and Weed [2] make a strong plea for performing hysterectomy in women with vaginal agenesis and cervical atresia when associated with functional endometrium. Our case supports their conclusions. In addition, timely surgery to prevent worsening of endometriosis is important. Clement [l] described a case of spontaneous perforation of endometriotic colon and concluded that perforation of the colon should be considered in the differential diagnosis of an acute abdomen in a patient with endometriosis who is pregnant or being treated by progestagens. Rud [4] also described a spontaneous bowel perforation of colonic endometriosis in a pregnant women, timely recognized and successfully managed. This report illustrates the possible grave consequences of neglected lower genital tract atresia when associated with functional endometrium. An unusual aspect in our case, however, is that the regional social-cultural traditions dictated the treatment delay.
Y.N. Bakri A. Tayeb A. Amri
Department
of Obstetrics and Gynecology King Faisal Specialist Hospital and Research Centre Riyadh, Saudi Arabia
Int J Gynecol Obstet 37
302
Letters to the Editor
References
4
Clement PB: Perforation of the sigmoid colon during pregnancy. A rare complication of endometriosis. Br J Obstet Gynaecol 84: 548, 1977. Geary WL, Weed JC: Congenital atresia of the uterine cervix. Obstet Gynecol 42: 213, 1973. Jacob JH, Griffin WT: Surgical reconstruction of the congenitally atretic cervix. Obstet Gynecol Surv 44: 556, 1989.
Rud BA: Colon-endometriose med perforation graviditet. Ugesker Laeg 141: 2831, 1979.
under
Correspondenceto: Y.N. Bakri Department of Obstetrics and Gynecology (MBC-52) King Faisal Specialist Hospital and Research Centre PO Box 3354, Riyadh 11211 Kingdom of Saudi Arabia
Uterine tamponade-drain for hemorrhage secondary to placenta previa-accreta To the Editor
January 3rd, 1992
Bleeding from placenta previa/accreta of the lower uterine segment, during cesarean section operation or its immediate postpartum period, portrays a difficult management problem in obstetrics. Approach to control such a bleeding depends upon the individual case, and includes uterine packing [1,2], bilateral uterine artery ligation, bilateral hypogastric artery ligation, transcatheter arterial embolization, and hysterectomy. We utilized a simple technique of multiple balloons packing plus hemostatic cushion with or without bilateral hypogastric arterial ligation, as determined by the clinical state, and found it helpful in achieving hemorrhage control, without the need to perform hysterectomy in selected patients of placenta previa/accreta. When a bleeding placental bed is recognized during cesarean section, and before closing the uterine hysterotomy incision, the surgeon introduces into the uterine cavity, a total of live to ten Foley catheters, size 22-24 french each with a 35-75 cm3 balloon. The surgeon introduces each catheter while an assistant, with hand in the vagina, pulls down the catheter’s distal end until all the catheters are appropriately placed. Before inflating the balloons, a hemostatic substance such as microfibrillar collagen hemostat (Avetine; Alcon Inc., Humacao, Puerto Rico) or oxidized regenerated cellulose (Surgicell; Johnson and Keywords: Uterine tamponade-drain; Hemorrhage.
Int J Gynecol Obstet 37
Placenta previa-accreta;
Johnson, New Brunswick, NJ) or gelatin sponge (Gelfoam; Upjohn Co., Kalamazoo, MI) is applied to the oozing inner surface of the lower uterine segment, to function as a hemostatic cushion.
Fig. 1. Schematic drawing of intrauterine hemostatic substance cushion.
balloons
and
301 and Obstetrics
Letters to the Editor Fatal perforation of endometriotic colon To the Editor
December 20th, 1991
Perforation of the bowel secondary to endometriosis is rare with only three cases reported [1,4]. We describe a patient with vaginal agenesiscervical atresia, who had a fatal septic peritonitis secondary to perforation of endometriotic colon. The patient, a 19-year-old woman, was admitted because of primary amenorrhea, recurrent pelvicabdominal pain, low-back pain, constipation, and abdominal mass. Laparoscopy done 2 years earlier, revealed severe endometriosis. Reconstructive vaginal-uterine surgery was advised then, but was declined because of social-cultural reasons, she received medroxy progesterone acetate (proVera) instead. On admission, clinical examination and imaging studies revealed a large pelvicabdominal mass which was partially cystic. IVP manifested mild bilateral hydroureters. Laboratory investigations were within normal limits. The need to establish a conduit for menstrual egress was stressed, but again declined. The family consented for exploratory laparotomy only, leaving the final decision of extirpative or reconstructive surgery until after marriage. Laparotomy revealed a hematometra, bilateral hematosalpinx, multiple chocolate cysts, and upper sigmoid colon endometrioma. Evacuation of chocolate cysts was performed with biopsies documenting endometriosis. Postoperative recovery was uneventful and the patient was discharged on day 5. She took provera 20 mg p.o. daily. Six weeks later she was readmitted with symptoms and signs of acute abdomen. An emergency laparotomy revealed a massive fecal contamination seeping through a 3 x 2 cm perforation involving a sigmoid colon endometrioma. Surgery was complicated by intraoperative cardiac arrest Keywords: Peritonitis.
Vaginal
agenesis;
Cervical
atresia;
Endometriosis;
but normal cardiac activity resumed after 4 min of resuscitation. Transverse colostomy was performed and multiple Jackson-Pratt (Heyer Schulte Co., Goletta, California, USA) drains were placed in the pelvis and abdomen. She developed septic shock, irreversible disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS) and expired on postoperative day 8. In a comprehensive literature survey of cervical atresia, Jacob and Griffin [3] concluded that although surgical intervention is mandatory to prevent hematometra, disabling pelvic pain, and unabated endometriosis, hysterectomy remained the definitive therapeutic modality. Geary and Weed [2] make a strong plea for performing hysterectomy in women with vaginal agenesis and cervical atresia when associated with functional endometrium. Our case supports their conclusions. In addition, timely surgery to prevent worsening of endometriosis is important. Clement [l] described a case of spontaneous perforation of endometriotic colon and concluded that perforation of the colon should be considered in the differential diagnosis of an acute abdomen in a patient with endometriosis who is pregnant or being treated by progestagens. Rud [4] also described a spontaneous bowel perforation of colonic endometriosis in a pregnant women, timely recognized and successfully managed. This report illustrates the possible grave consequences of neglected lower genital tract atresia when associated with functional endometrium. An unusual aspect in our case, however, is that the regional social-cultural traditions dictated the treatment delay.
Y.N. Bakri A. Tayeb A. Amri
Department
of Obstetrics and Gynecology King Faisal Specialist Hospital and Research Centre Riyadh, Saudi Arabia
Int J Gynecol Obstet 37
302
Letters to the Editor
References
4
Clement PB: Perforation of the sigmoid colon during pregnancy. A rare complication of endometriosis. Br J Obstet Gynaecol 84: 548, 1977. Geary WL, Weed JC: Congenital atresia of the uterine cervix. Obstet Gynecol 42: 213, 1973. Jacob JH, Griffin WT: Surgical reconstruction of the congenitally atretic cervix. Obstet Gynecol Surv 44: 556, 1989.
Rud BA: Colon-endometriose med perforation graviditet. Ugesker Laeg 141: 2831, 1979.
under
Correspondenceto: Y.N. Bakri Department of Obstetrics and Gynecology (MBC-52) King Faisal Specialist Hospital and Research Centre PO Box 3354, Riyadh 11211 Kingdom of Saudi Arabia
Uterine tamponade-drain for hemorrhage secondary to placenta previa-accreta To the Editor
January 3rd, 1992
Bleeding from placenta previa/accreta of the lower uterine segment, during cesarean section operation or its immediate postpartum period, portrays a difficult management problem in obstetrics. Approach to control such a bleeding depends upon the individual case, and includes uterine packing [1,2], bilateral uterine artery ligation, bilateral hypogastric artery ligation, transcatheter arterial embolization, and hysterectomy. We utilized a simple technique of multiple balloons packing plus hemostatic cushion with or without bilateral hypogastric arterial ligation, as determined by the clinical state, and found it helpful in achieving hemorrhage control, without the need to perform hysterectomy in selected patients of placenta previa/accreta. When a bleeding placental bed is recognized during cesarean section, and before closing the uterine hysterotomy incision, the surgeon introduces into the uterine cavity, a total of live to ten Foley catheters, size 22-24 french each with a 35-75 cm3 balloon. The surgeon introduces each catheter while an assistant, with hand in the vagina, pulls down the catheter’s distal end until all the catheters are appropriately placed. Before inflating the balloons, a hemostatic substance such as microfibrillar collagen hemostat (Avetine; Alcon Inc., Humacao, Puerto Rico) or oxidized regenerated cellulose (Surgicell; Johnson and Keywords: Uterine tamponade-drain; Hemorrhage.
Int J Gynecol Obstet 37
Placenta previa-accreta;
Johnson, New Brunswick, NJ) or gelatin sponge (Gelfoam; Upjohn Co., Kalamazoo, MI) is applied to the oozing inner surface of the lower uterine segment, to function as a hemostatic cushion.
Fig. 1. Schematic drawing of intrauterine hemostatic substance cushion.
balloons
and