INTRODUCTION
Uterine
leiomyoma, commonly termed fibroid is the most
common pelvic tumour encountered in
reproductive-aged women.1,2 Most
are asymptomatic; symptomatic cases present with
abnormal uterine bleeding, pressure symptoms and rarely severe abdominal pain.3 Pain
maybe related to cervical dilatation by a submucous myoma protruding through
the cervix, red degeneration during pregnancy or torsion of a pendunculated fibroid nodule.4 The
later is a rare occurrence.
Reports
of torsion of a penduculated subserous uterine fibroid,
with or without pregnancy, are infrequent in
the literature. The majority of such infrequent
reports record that most cases
occur during pregnancy or the puerperium.3
In patients with subserous uterine fibroid, the incidence of torsion is
less than 0.25%5. Torsion uterine fibroid in association with peritoneal collection
can poise diagnostic dilemma, as the clinical presentation can be non-specific,
ranging from mild abdominal discomfort to acute abdomen with shock.6,7 Differential
diagnoses
include accidented ovarian
cyst, ectopic pregnancy, ovarian tumour, leiomyosarcoma etc.3,6,8. The diagnosis of torsion of a pedunculated subserous fibroid can be aided by imaging techniques such as
ultrasound scan with high Doppler flow, MRI or CT but the definitive diagnosis
is usually at laparotomy.8,9 This
is a case report of torsion of a subserous uterine fibroid with massive ascites
requiring emergency laparotomy and myomectomy.
CASE REPORT
Miss N.P,
a 28-year old P0+1, was admitted in the accident and emergency department of the Rivers State University
Teaching Hospital on
07/04/2023 with complaint of abdominal pain of
one week duration. Her LMP was on 01/04/2023.
The
pain was initially located around her lower abdomen, and became generalized
on the day of presentation. There was associated abdominal swelling which had
progressively increased in size. There were several episodes
of vomiting, and the vomitus contained
recently ingested meals. There were no changes
in her bowel habit, and there was no history of trauma
or abdominal massage. There was a history
of dizziness and weakness but no fainting spells.
Physical examination revealed a young lady that was in painful distress, mildly pale,
anicteric and mildly dehydrated. Her chest was clinically
clear with a respiratory rate of 20 cycles per minute.
Her pulse was 120 beats per minute and blood pressure 118/70mmHg. Her abdomen
was distended, with generalized tenderness and
guarding (which precluded assessment of her liver, spleen and
kidney as well as any abdominal or pelvic masses). Vaginal examination revealed a normal vulva and vagina; her cervix
was posterior. The adnexae and pouch of Douglas
were full and tender. The gloved finger used for examination was smeared with altered blood. An assessment of acute abdomen 20 ? accidented ovarian
cyst was made.
Pregnancy
test done was negative. An urgent ultrasound
scan done showed right complex ovarian cyst with massive hemoperitoneum.
Packed cell volume estimation was 36%. She was counselled on
the diagnosis and management modality. A signed informed consent
was obtained and she was prepared for emergency laparatomy.
Her intra-operative findings were four liters (4L)
of straw coloured ascitic fluid, hemorrhagic
torsioned huge pedunculated
fibroid (which weighed 2.7kg),
and posterior wall subserous
fibroid ~12 X 10cm. The adnexae were normal. Myomectomy
was done, and the anterior abdominal wall was closed
with absorbable sutures. Samples were
sent for histological analysis. Her post-operative period was
uneventful. She was discharged home on oral medications and followed up on
outpatient basis.
DISCUSSION
Uterine
fibroid is most common benign gynaecologic tumour affecting women of reproductive age.1,2 The usual presentation are abdominal swelling, pressure
symptoms, abnormal uterine bleeding, infertility etc 7. It is not common that uterine fibroid
cause acute complication such as torsion associated with ascites or
hemoperitoneum.4,10 In
the literature few cases have been reported. Tondera et al reported the first case of
acute abdomen due to torsion of a calcified penduculated myoma in 1952.9
Risk
for torsion increases when the pedicle is thin and the length is long enough to
cause excess motility of the myoma. Other risk
factors for torsion of an uterine
fibroid include
increased weight of the fibroid mass, and softening of the fibroid
during pregnancy.4,11,12 Miss
NP had a huge fundal penduculated fibroid similar to
the case reported by Ward et al and Charles K et al.9,11
Torsion
of any pelvic organ usually presents with sudden, severe abdominao-pelvic pain
that is usually unresponsive to analgesics.
The pain is due to ischemia of the vascular pedicle and compressive nature of
the torsion process.9,13 Miss
NP had acute onset abdominal pain that was initially localized but later became generalized and not
amenable to analgesics. Peritoneal collection in association with this
condition had been reported in literature, and is either
due to ascites or haemoperitoneum. Miss NP had a peritoneal
collection initially thought to be haemoperitiomen 20
accidented ovarian
cyst but at laparotomy it was found to be ascites.
Ascitic fluid in association with a benign
condition had been attributed to various causes which include anoxia and
release of toxins
due to torsion which then causes damage and increase
tissue permeability, exudation from extensive neovascularization
of the tumour, peritoneal mechanical irritation
by the tumour, loss of balance between secretion and absorption
in the presentation of a pathology.14 In a case reported by
Okaro et al, ascites was
attributed to mechanical irritation of the tumour.13 There could
likely be an interplay of the above theories in the case of Miss NP.
Misleading
clinical symptoms coupled with the rarity of the condition may result in missed
pre-operative diagnosis.7,15 Clinical
symptoms varies from mild abdominal discomfort to acute cardiovascular shock.
It could be suspected from the medical history
of a fibroid pre-existing in the patient. For Luk et
al and Foissac et al,6,8
there was prior knowledge of existing uterine fibroids in their patients. Thus it prevented misdiagnosis but
in the case of miss NP, she denied prior knowledge of any abdominal mass.
Imaging
techniques can aid pre-operative diagnosis. Ultrasound scan is the widely available modality and can exclude the presence of an adnexal
mass, but if a normal ovary is not observed, definitive
diagnosis becomes inconclusive.15 The sensitivity
of ultrasonography is however operator-dependent,
and subject to interpretative bias.16 In a
case report by Gaym et al, Gaye et al and
Thanasas et al,
they missed the diagnosis as was in the case of miss
NP. 3,17,18 An ultrasound scan exam with
Doppler interrogation is more effective for the detection, mapping
and characterization of myomas and making an assessment
of organ vascularity. It is more sensitive than a CT
scan, but MRI is more effective in comparison to ultrasound
scan.8,19,20,21 Pre-operative diagnosis was
possible with CT scan for the cases reported by David Le et al, Tavernaraki et al, and Chang et al.19,22,23
While for Durai et al, MRI was the imaging
tool that cletch the pre-operative diagnosis of
torsion fibroid.22,24 However, access to these imaging modalities is
limited in poor resource setting like ours due to
cost and or limited availability. Miss NP presented with abdominal pain,
abdominal distension and tachycardia coupled with ultrasound findings of
complex ovarian mass. Her pre-operative
diagnosis was accidented (ruptured)
ovarian cyst with hemoperitoneum.
If
torsion is left untreated, hemorrhagic infarction of the myoma
can lead to systemic infection and death.18,24
Once diagnosis is made, pre-operatively or intraoperatively,
treatment include derotation and myomectomy, which can be
undertaken either by
laparotomy or laparoscopy (in cases of fibroids < 10cm); hysterectomy may be offered to post-menopausal
women with no desire for children.24
Miss NP had abdominal myomectomy with uneventful post
operative period.
CONCLUSION
The
diagnosis of torsion fibroid is challenging pre-operatively
due to the rarity of the condition and occasional sonographic misdiagnosis. Therefore, a
high index of suspicion is needed in women of
reproductive age who present with acute abdomen
and a history or findings of an abdomino-pelvic mass.
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