Generalized peritonitis with pneumoperitoneum caused by the spontaneous perforation of pyometra without malignancy: report of a case

Pyometra Puzzler: Unraveling Senile Endometritis in an Unconventional Presentation

Pyometra is a very uncommon condition in postmenopausal women that rarely improves with standard antibiotic treatments. It is usually overlooked as the patient presents with vague symptoms. Our case presented a postmenopausal woman with sepsis due to a huge pyometra. Swabs for sensitivity, tubercular gene testing, and basic blood workup were done, and the patient was started on intravenous antibiotic therapy. Pyometra drainage could not be done due to thin, friable uterine walls. When the patient had improved, a clinically total abdominal hysterectomy was done after ruling out malignant causes. Delay in the diagnosis of this condition may lead to perforation, which may, in turn, cause peritonitis, which may gravely affect the patient.

Massive Pyometra Due to Senile Endometritis in a Postmenopausal Woman: A Rare Entity

An 83-year-old postmenopausal female P5L5 (all full-term normal deliveries) presented with complaints of foul-smelling purulent discharge per vagina for 15 days associated with pain in abdomen. A midline mass was palpable per abdomen in the suprapubic region corresponding to 16 weeks size gravid uterus, which was soft to firm in consistency. On examination per vaginum, the atrophied cervix was found flush with the vagina and purulent discharge was seen draining through the cervix. Blood reports showed raised total leucocyte count with granulocyte predominance. Abdominal ultrasonography revealed a uterine cavity filled with echogenic contents, with no abdominal cavity collection. The patient was started on IV antibiotics and planned for dilatation and curettage. On histopathology acute on chronic senile endometritis was found with no evidence of malignant cells. Tuberculosis gene testing was found to be negative. We conclude that the senile endometritis leading to cervical stenosis as seen during dilatation and curettage had led to the pyometra and no evidence of malignancy was found.

Damage control surgery for spontaneous perforation of pyometra with septic shock: a case report

Background

Although spontaneous perforation of pyometra is very rare, it sometimes causes severe peritonitis, leading to lethal conditions. Damage control surgery reportedly improves the survival of critically ill patients; however, there has been no report describing damage control surgery for ruptured pyometra.

Case presentation

An 83‐year‐old postmenopausal woman with generalized peritonitis and septic shock was admitted and underwent emergency laparotomy. Abbreviated surgery was carried out because of progressing septic shock, and planned reoperation was carried out 2 days after the initial surgery. Histopathological examination revealed the perforation of pyometra with no evidence of malignancy. The patient was discharged on the 32nd postoperative day in stable condition.

Conclusion

We report a case of spontaneous perforation of pyometra with severe septic shock successfully treated by damage control surgery. Damage control surgery is a useful treatment option for hemodynamically unstable patients with diseases in the field of obstetrics and gynecology.

Generalized peritonitis secondary to spontaneously perforated pyometra in elderly women:two cases with different clinical courses and surgical approaches and review of the literature

We describe two cases of spontaneously perforated pyometra (SPP) in elderly women treated with two different surgical approaches. An 88-year-old woman underwent emergency laparotomy for presumed diagnosis of gastrointestinal (GI) tract perforation. During surgery, SPP and a tumor of the sigmoid colon were identified. Total hysterectomy and sigmoid colon resection were performed. Despite exhaustive postoperative treatments, the patient died on postoperative day (POD) 189 due to peritonitis and pneumonia. A 93-year-old woman with acute abdomen was diagnosed with severe pyometra and primarily treated with transcervical drainage. Due to progression of generalized peritonitis, laparoscopic surgery was performed. Intraoperatively, scar from a uterine body perforation was identified, leading to the diagnosis of SPP. Only peritoneal irrigation and drainage were performed, in consideration of her advanced age. She improved and was discharged from the hospital on POD 35. The prognosis for SPP is sometimes poor, especially in older women. Minimally invasive surgical intervention might be considered for primary treatment in such cases.

Spontaneous Perforation of Pyometra

Pyometra is collection of purulent material which occurs when there is interference with its normal drainage. It is an uncommon condition with incidence of 0.1 to 0.5% of all gynecological patients. Spontaneous rupture of uterus is an extremely rare complication of pyometra. A 65-year-old lady presented with pain abdomen and purulent vaginal discharge. Preoperative diagnosis of pyometra was made by magnetic resonance imaging (MRI). Laparotomy followed by peritoneal lavage and repair of perforation was performed. Although spontaneously perforated pyometra is rare, the condition must be borne in mind with regard to elderly women with acute abdominal pain. Preoperative diagnosis of perforated pyometra is absolutely essential. Computed tomography (CT) and MRI are diagnostic tools. In selected cases conservative approach at surgery can be opted.

A Case Report and Literature Review of Spontaneous Perforation of Pyometra

BACKGROUND

Pyometra is defined as an accumulation of purulent material in the uterine cavity. Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen.

CASE REPORT

We report a rare and difficult case of peritonitis in an elderly female that was caused by a spontaneous perforation of pyometra. A 90-year-old postmenopausal woman was referred to our hospital with complaints of vomiting, fever, and abdominal pain. Computed tomography revealed a large amount of ascites, cystic mass in the uterus, and intraperitoneal and intrauterine air. Transvaginal ultrasound demonstrated a thin area around the fundus. An emergency laparotomy was performed for the suspected gastrointestinal perforation or perforation of pyometra. At laparotomy, copious purulent fluid was present in the peritoneal cavity; however, no perforation of the gastrointestinal tract was observed. We identified a perforation site over the uterine fundus and purulent material exuding from the cavity. Subsequently, hysterectomy and bilateral salpingo-oophorectomy were performed. The patient was discharged on postoperative day 13 with no complications. Histopathologic studies revealed endometritis and myometritis with no evidence of malignancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With diffuse peritonitis, ruptured pyometra should be considered, even in elderly female patients. This case illustrates the importance of clinical knowledge of acute gynecologic diseases. Here we also review the perforation of pyometra with no evidence of malignancy.

Spontaneous perforation of pyometra presenting as acute abdomen: a rare condition with considerable mortality

Pyometra is an uncommon and potentially lethal disease that occurs mainly in postmenopausal women. Spontaneous perforation of pyometra presenting as acute abdomen is an extremely rare complication of pyometra, and the patients are always admitted to the emergency department. An additional case is reported herein. In addition, a literature review was performed between 1949 and 2015. A correct preoperative diagnosis was made in 21.05% of all the cases. Of all cases, 25.71% were associated with malignant disease. The mortality rate of spontaneous perforation of pyometra is 31.88%. Thus, it should be considered in the differential diagnosis of acute abdomen in elderly women. Total hysterectomy along with bilateral salpingo-oophorectomy is the preferred treatment. Administration of broad-spectrum antibiotics and postoperative intensive care support are essential to reduce the high mortality.

Spontaneous rupture of pyometra manifesting as an acute abdomen: a case report

Spontaneous perforation of pyometra is a rare entity with a reported incidence in the range of 0.01-0.05%. The clinical picture is similar to peritonitis arising from intestinal perforation and commonly the correct diagnosis is only made perioperatively. We report a case in an elderly postmenopausal woman presenting with an acute abdomen.

Spontaneous uterine perforation caused by pyometra: a case report

Introduction:

Pyometra is an accumulation of purulent material or pus in the uterine cavity. Spontaneous perforation of uterus by pyometra is rare. This is a clinical presentation and management of a spontaneous perforation of uterine caused by pyometra.

Case Presentation:

This is a case report on spontaneously perforated associated with pyometra secondary to cervical malignancy. The patient underwent exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy.

Conclusions:

Spontaneous rupture of pyometra duo to cervical cancer in cases of acute abdomen in elderly patients should be considered.

Spontaneous rupture of pyometra - a rare cause of peritonitis in elderly female

The incidence of spontaneous perforations in pyometra is rare, being 0.01-0.5% in gynaecological patients. However, they are more common in postmenopausal females and their incidence is 13.6%. Here, we are reporting a rare case of peritonitis with a pneumoperitoneum in an elderly female, which was caused by a spontaneous perforation of pyometra. A 74-years old postmenopausal female with uncontrolled diabetes mellitus was admitted to surgical emergency with signs of diffuse peritonitis and she was in shock. After resuscitation, an emergency laparotomy was performed because of suspicion of a hollow viscous perforation with peritonitis. At laparotomy, about 2000ml of purulent fluid was found to be present in peritoneal cavity, while alimentary tract was intact. A rent with a diameter of 0.8 cm was found on fundus of uterus. A total abdominal hysterectomy with a bilateral salphingo oophorectomy was performed. Patient got discharged on 12(th) post-operative day without major complications. Histopathological studies revealed endometritis and myometritis, with no evidence of malignancy.

Spontaneous perforation of pyometra: a report of seven cases and review of the literature

BACKGROUND/AIMS

The spontaneous perforation of pyometra is very rare and is associated with a poor prognosis. The present study aimed to evaluate the clinical characteristics and prognostic factors for patient survival.

PATIENTS AND METHODS

We reported on 7 patients with spontaneous rupture of pyometra. We also reviewed 47 additional published cases. Thus, all 54 patients were analyzed for mortality.

RESULTS

We investigated the prognosis in 44 of 54 patients, excluding 8 patients with undocumented outcome and 2 who died of other diseases. The mortality rate was 25% (11 of 44). In univariate analysis, variables such as age, correct preoperative diagnosis, comorbidities, the presence of malignancy, and hysterectomy were not significant between surviving and deceased patients. In bacterial cultures from the peritoneal cavity, the most common etiological organisms were Escherichia coli and anaerobes such as Bacteroides and Peptococcus species. The rate of isolation of anaerobic bacteria was significantly increased in patients who died (odds ratio, 6.33; 95% confidence interval, 1.28-31.02; p = 0.04).

CONCLUSION

Antibiotic therapy for E. coli and anaerobes should be considered in patients with spontaneous perforation of pyometra.

Clinical characteristics of perforated pyometra and impending perforation: specific issues in gynecological emergency

OBJECTIVE

To evaluate the clinical characteristics of pyometra and the differences between perforated pyometra and early-drained pyometra in order to prevent morbidity.

MATERIAL AND METHODS

Retrospective study of 14 patients diagnosed between 1998 and 2008 with early-drainage pyometra and six patients with perforated pyometra were included. In addition, a review of the literature yielded another 30 perforated pyometra cases for comparison.

RESULTS

Of 20 women with pyometra, the main presented symptoms at admission were abdominal pain (80%), fever (45%) and vaginal discharge (25%). The majority of organisms isolated were Bacteroides fragilis (seven cases), Streptococcus species (six cases) and Escherichia coli (five cases). Of the 36 cases with spontaneous uterine perforation to date, 35 cases (97%) had abdominal pain, 11 cases (31%) had fever, and 10 cases (27%) had vomiting. Hypoalbuminemia was found in seven patients (five cases in the perforation group and two cases in the drainage group).

CONCLUSION

Early diagnosis of pyometra before perforation can avoid surgical exploration and decrease morbidity and mortality. Perforated pyometra should be considered as a differential diagnosis in women with pneumoperitoneum and fever. Hypoalbuminemia should be considered as a predisposing factor for pyometra perforation.

Spontaneous uterine perforation due to pyometra presenting as acute abdomen

Spontaneous perforation of the uterus is rare, its incidence being about 0.01% − 0.05%. We report a rare case of diffuse peritonitis caused by spontaneously perforated pyometra. A 63-year-old woman with severe abdominal pain was admitted to our hospital. Laparotomy was performed because of the suspicion of gastrointestinal perforation with generalized peritonitis. At laparotomy, about 900 mL of pus was found in the peritoneal cavity. There were no abnormal findings in the alimentary tract, liver, or gallbladder. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathological investigation of the surgical specimen revealed endometritis and myometritis of the uterus; but there was no evidence of malignancy, and the cervical canal was patent. Although spontaneously perforated pyometra is rare, a perforated pyometra should therefore also be considered when elderly women present with acute abdominal pain.

Spontaneous perforation of pyometra

Pyometra is the accumulation of purulent material in the uterine cavity. Its reported incidence is 0.01−0.5% in gynecologic patients; however, as far as elderly patients are concerned, its incidence is 13.6% [3]. The most common cause of pyometra is malignant diseases of genital tract and the consequences of their treatment (radiotherapy). Other causes are benign tumors like leiomyoma, endometrial polyps, senile cervicitis, cervical occlusion after surgery, puerperal infections, and congenital cervical anomalies. Spontaneous rupture of the uterus is an extremely rare complication of pyometra. To our knowledge, only 21 cases of spontaneous perforation of pyometra have been reported in English literature since 1980. This paper reports an additional case of spontaneous uterine rupture.

Computed tomography features of spontaneously perforated pyometra: a case report

Spontaneous perforation of pyometra is an extremely rare emergent gynecologic disease. We report a 73-year-old woman with a spontaneously perforated pyometra presenting with acute abdomen in the emergency department. A dedicated computed tomography examination of the abdominal and pelvic regions revealed the diagnosis. The patient recovered well after surgical intervention and antibiotic treatment.

Effect of Escherichia coli and Lactobacillus rhamnosus on macrophage inflammatory protein 3 alpha, tumor necrosis factor alpha, and transforming growth factor beta release by polarized rat uterine epithelial cells in culture

Entry of bacteria from the vagina into the uterus raises the question of uterine epithelial cell (UEC) signaling in response to the presence of bacteria. Our model system helps to define microbially elicited UEC basolateral cytokine release, important in regulating underlying stromal immune cell protection. UECs from adult rats were grown in cell culture inserts to establish a confluent polarized monolayer as was determined by transepithelial resistance (TER). Polarized epithelial cell cultures were treated apically with live or heat-killed Escherichia coli or Lactobacillus rhamnosus prior to collection of basolateral media after 24 h of incubation. Coculture of polarized UECs with live E. coli had no effect on epithelial cell TER. In response to exposure to live E. coli, epithelial cell basolateral release of macrophage inflammatory protein 3 alpha (MIP3 alpha) and tumor necrosis factor alpha (TNF-alpha) increased at a time when basolateral release of biologically active transforming growth factor beta (TGF-beta) decreased. Incubation of UECs with heat-killed E. coli resulted in an increased basolateral release of MIP3 alpha and TNF-alpha, without affecting TER or TGF-beta. In contrast to E. coli, live or heat-killed L. rhamnosus had no effect on TER or cytokine release. These studies indicate that polarized rat UECs respond to gram-negative E. coli by releasing the cytokines MIP3 alpha and TNF-alpha, signals important to both the innate and adaptive immune systems. These findings suggest that UEC responses to bacteria are selective and important in initiating and regulating immune protection in the female reproductive tract.