O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 3 | 26 and internal pressure from rapid growth of the mass are the likely explanations. 1,5,6 ere can also be iatrogenic rupture during surgery in 1% of cases. 2,7 e clinical presentation of rupture of a dermoid cyst, however, depends on the way the cyst has ruptured. Sudden rupture may result in acute peritonitis, hemorrhage and shock whereas slow leak from a tear in the cyst wall will result in chronic granulomatous peritonitis. e symptoms and signs may be subtle in the beginning of the leak, although the patient will complain of progressive abdominal distension and pain due to settling in chemical peritonitis which may be associated with gastrointestinal disturbances such as anorexia, nausea, vomiting and diarrhea. 2,14 e chronic granulomatous peritonitis, which is a chemical peritonitis due to aseptic in ammatory peritoneal reaction secondary to intra-peritoneal spillage of dermoid cyst contents is characterized by numerous nodular implants widespread on the peritoneal surface, dense adhesions, diffuse or focal omental infiltration and inflammatory masses involving the omentum and bowel, and ascites that simulate carcinomatosis or tuberculous peritonitis. Ascitic fluid collection can occur in bilateral paracolic gutters, between the mesenteric leaflets and in subphrenic spaces. 1,5,16,18 The complications of chronic peritonitis include bowel obstruction, abdominal wall abscesses and entero-cutaneous fistula formation. 1,2,5,7,14 Transvaginal sonography (TVS) is the imaging modality of choice. 2 The typical ultrasound findings of dermoid cyst include Rokitansky nodule, dermoid mesh and the “tip of iceberg sign”. The Rokitansky nodule is a densely echogenic tubercle projecting into the cystic lumen. Dermoid mesh refers to hyperechogenic lines arising from hairs, sebaceous material may also appear echogenic and there can be areas of calcification. 2,6 However, accuracy of ultrasound in diagnosing torsion or rupture of dermoid cyst is poor. 2 For suspected rupture of dermoid cyst, CT scan is the imaging modality of choice with 88% accuracy as it can detect ruptured cyst contents presenting as omental infiltration, perilesional fat stranding, fatty fluid in the peritoneal cavity including cul-de-sac and antedependent pockets and intraperitoneal implants around the peritoneal surface of the bowel, liver and omentum. 1,8 MRI imaging has excellent sensitivity for detecting fat and calcification, although MRI does not provide additional information over CT scan. 5 If acute rupture of dermoid cyst or chronic chemical peritonitis is suspected, the treatment is surgical exploration with suctioning of spilled ovarian cyst contents, a thorough peritoneal wash, cystectomy or adenexectomy, and adhesiolysis. 3,4.8,16 If there is suspicion of malignancy or tuberculosis, as chronic granulomatous peritonitis can mimic carcinomatosis, a biopsy with frozen- section is helpful in differentiating the granulomatous response from malignancy or tuberculosis. Conservative surgery is usually warranted which includes removal of the ovary with dermoid cyst. The opposite ovary and uterus can be removed if they deem to be extensively inflammed. Moreover, in patients with significant residual inflammatory masses, use of postoperative corticosteroids has been described in some of the case reports. 3,8,9,14 Other authors have reported initial exploratory laparotomy and peritoneal lavage followed by subsequent surgical procedures such as adhesiolysis, cystectomy, oophorectomy, total abdominal hysterectomy with bilateral salpingo-oopherectomy. 7 In the index patient there was history of abdominal pain and gradual distension of the abdomen for three months that indicates that the cyst had ruptured a few months prior but in the beginning symptoms were mild. However, with gradual build up of the ascitic fluid, keratin granulomas and chronic chemical peritonitis the pain got worse over time. She presented to the health facility with extreme pain due to severe abdominal distension and acute peritonitis. The chronic chemical peritonitis had caused dense adhesions and a frozen abdomen, all tissues were inflamed. Almost two litres of ascitic fluid was collected in the peritoneal cavity. The unusual finding, however, was the presence of almost similar size of large amount of keratin globules. Some globules were adhered to the peritoneal surface of bowel while others were floating in the abdominal cavity. Since, there was no history of sudden pain suggestive of torsion, no history direct trauma, no malignant transformation on histology, the spontaneous rupture is the most likely explanation in this case. The patient underwent exploratory laparotomy because she presented with an acute abdomen. However, due to the frozen abdomen consequent to extensive chemical peritonitis and highly inflamed tissues only suctioning of peritoneal fluid followed by rigorous peritoneal lavage was performed without any further surgical exploration. A diagnosis of ruptured teratoma was made based on histology report of globules and abdominopelvic CT scan and MRI reports. Further, guided by the literature a short course of steroids was given with the hope that steroids will help mitigate the inflammation. Moreover, a short course of steroids neither affects tissue healing nor causes adrenal suppression. The second surgery was performed after 8 weeks of primary surgery. During this interval period inflammation had subsided remarkably, anatomy was discernable, although the cyst was adherent to the adjacent structures which was successfully removed after adhesiolysis. Postoperatively, the patient made complete recovery and was discharged home. Conclusion This case illustrates that chemical peritonitis secondary to spontaneous rupture of a dermoid cyst is a rare condition which can have an acute or chronic presentation. In chronic form, it presents as gradually increasing abdominal discomfort and distension with or without gastrointestinal symptoms. 5 The diagnosis should be considered in every case of unexplained chemical peritonitis especially when associated with fat or keratin globules and/or calcified hepatic, subphrenic or peritoneal deposits. 5 There is limited data in published literature for management of chronic granulomatous peritonitis following rupture of an ovarian cystic teratoma. In most published cases, exploratory laparotomy was performed which can be done with both laparoscopy and conventional surgery, although laparotomies are more common. 1,4,9 The index patient underwent exploratory laparotomy; however, due to the frozen abdomen secondary to extensive inflammation only peritoneal lavage was performed at the time of primary surgery. Removal of cyst contents from the peritoneal cavity, a short course of steroids and an interval period of 8 weeks, all helped reduce inflammation whereby follow up surgery could be successfully performed. WC: 2039 Abbreviations CT: Computed tomography MRI: Magnetic resonance imaging TVS: Transvaginal sonography Ethical Approval: The local Human Research Ethics Committee ruled that a literature review is a low-risk research activity and does not require a formal ethics application. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Consent: The authors received no financial support for the research, authorship, and/or publication of this article. Conflicts of Interest: The authors declare that they have no competing interests. O&G Forum 2021; 31: 23 - 27 CASE REPORT