A surprising diagnosis

NN is an 18-year-old female patient who complained of abdominal distension for the last 2 years. She had been followed up in another facility and she had a CT scan of the abdomen done.

The report was as follows: COMPLEX MESENTERIC CYST, or COMPLEX LEFT LIVER  LOBE  CYST, or DERMOID  CYST.

In spite of the radiological report, she was never given any treatment option. She was just referred from one hospital to the other.

She came to Chaaria for opinion.

I have therefore repeated an abdominal U/S and, at the epigastrium- mesogastrium, I have noticed a cystic mass with some solid parts in the lower pole. The cyst was actually very big and measuring about 20 cm diameter. Because most of it contained clear liquid, I was convinced it could have been benign. At U/S I have also noticed a semi-solid mass at the left ovarian site, which I have classified as tubo-ovarian mass, probably unrelated to the big abdominal cyst.

I have decided to admit the patient and to attempt the operation, because NN was desperate and tired of being always referred elsewhere.  In case it would have been malignant and impossible to be excised, I would at least have tried… but I was honestly very optimistic. 

We opened the abdomen under general anesthesia because we expected to operate on a liver or mesenteric cyst, but with surprise we noticed that it was in fact a huge right ovarian cyst.

There were some adhesions with the omentum but easy to be released.

Finally we have removed the big cyst without much problem and with no bleeding.

Before closing the abdomen, we have gone to check on the small left tubo-ovarian mass previously seen at U/S: actually it was a dermoid cyst full of fatty material and hair.

We managed to remove the cyst without damaging the ovary.

I believe the young patient is somehow very lucky, because in both cases we have removed benign lesions and also because she still has one viable ovary: we hope she will conceive and have children, and we are sure the mass we have removed today will not cause her any further problem in future.

Another lesson we learnt from today’s clinical case is that abdominal CT scan can be sometime misleading and that there is still room for explorative laparatomy when the radiological findings do not match completely with actual conditions of the patient.

Dr Bro Giuseppe Gaido