Diverticulitis presenting as a tubo-ovarian abscess with subsequent colon perforation

A case-report on diverticulitis misdiagnosed as tubo-ovarian abscess

Introduction and importance

Tubo-ovarian abscesses (TOA) is presented with multiple clinical manifestations including gastrointestinal findings.

Case presentation

Herein, we present a case of complicated diverticulitis that was misdiagnosed as TOA, owing to overlapping genital involvement.

Clinical discussion

Imaging could be misleading in these patients as a result of severe inflammation of intestines and surrounding organs.

Conclusion

Patients who do not respond to antibiotic treatment should be suspected of other gastrointestinal pathologies such as diverticulitis and should be evaluated accordingly.

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Concomitant presentation of diverticulitis and Tubo-ovarian abscesses (TOA) has been rarely reported.

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Diverticulitis can also be complicated, indicated by the involvement of other organs such as ovaries and fallopian tube.

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In such cases, pathological evaluation, following the surgical intervention can indicate the exact disease.

Colo-ovarian Fistula complicating acute diverticulitis: Two cases and literature review

INTRODUCTION

Colonic diverticulosis is common in western world. Fistula formation occurs in 10-20 % of patients, usually as a consequence of an acute inflammatory process (diverticulitis). Fistulas from diverticulitis occur mainly to bladder, small bowel and uterus. Communication between colon and ovary occurred more frequently in the context of primary neoplasms of ovary, ovarian abscess or Crohn's disease. However, colo-ovarian fistula after acute colonic diverticulitis is a rare entity with few cases reported in literature.

PRESENTATION OF CASES

In this article, we described two cases. We also performed a literature review. In both cases, an initial conservative management for acute diverticulitis was performed. The maintenance of symptoms dictated further investigation. The presence of left ovarian abscess was presented, suggesting the presence of fistula.

DISCUSSION

Although the distinct evolution during the initial treatment, which results in different timing for surgery, en bloc resection of colon and adnexa was performed, with favorable outcomes. Final pathological analysis confirmed the diagnosis.

CONCLUSION

Colo-ovarian fistulas complicating acute diverticulitis are rare entities. In this article, we present our experience in the management of two cases, with different surgical approach but favorable outcomes.

Vegetable fibre in an infected ovarian dermoid cyst

Tubo-ovarian abscesses (TOAs) are inflammatory masses involving the fallopian tube, ovary and occasionally other adjacent pelvic organs. A 32-year-old woman with no significant medical history presented with a chief complaint of lower abdominal pain. Initial CT of the abdomen was suggestive of a colon abscess; however, a repeat CT suggested a TOA. The left ovary was densely adherent to the left pelvic sidewall and the rectosigmoid colon. The content of the ovary was consistent with a dermoid and suspected of superinfection. Pathological examination of the tissue revealed normal ovarian cortical tissue, hair cells, melanin, and epidermal and neural tissue, as well as evidence of a foreign object resembling vegetable matter. The vegetable fibre found in this patient's biopsy was of an unclear aetiology, but probably indicates a perforation of the bowel. Any cause of bowel perforation adjacent to the adnexa can lead to TOA, therefore providing a rational speculation for this case.

Colo-ovarian fistula

Colo-ovarian fistula is a rare entity. The case of a 54-year-old female with a colo-ovarian fistula is presented. We describe our experience in managing this complication of diverticulitis and propose a workup and treatment plan. Initial imaging and diagnostic studies are described. En-bloc resection of the sigmoid colon and ovary was performed. A review of the literature is presented.

Middlemore Hospital experience with tubo-ovarian abscesses: an observational retrospective study

AIM

The aim of this paper was to study the characteristics of patients presenting to Middlemore Hospital with tubo-ovarian abscess (TOA) and to compare the outcomes of conservative medical management versus medical management with surgical drainage and medical management with radiological drainage.

METHODS

All patients admitted with a radiologically or surgically proven TOA between January 01, 2008 and December 31, 2010, were included and followed up until June 30, 2011. The total number of patient/index admission was 174.

RESULTS

The mean age of patients was 37.8 years. One hundred thirty patients had medical treatment only with hospitalization and antibiotics, and 44 patients were managed with antibiotics and surgical drainage. Complete resolution of TOA was 77.3% (99/128) for patients managed medically and 93.2% (41/44) for patients managed surgically. When the two groups were compared, patients who were managed surgically were more likely to have complete resolution of TOA within 6 months of index admission with an odds ratio (OR) of 4 and a P-value of 0.029. There was no statistically significant difference in the secondary outcomes namely of readmission with TOA (OR: 0.47) and the need for repeat surgical or radiological drainage (OR: 1.48). Nonetheless, the relative duration of hospitalization was longer for the surgical group with a P-value of <0.0001. The C-reactive protein and the size of TOA were the significant factors involved in the resolution of TOA.

CONCLUSION

The results of this study confirmed our initial hypothesis that we should consider surgical drainage more often, probably earlier, especially for the younger patients still desiring fertility preservation and for larger abscesses. Laparoscopic surgical drainage is safe and could be used as the procedure of choice. Conservative medical management is still acceptable with good cure rates of 77%. C-reactive protein and the size of the abscess were the important factors to consider when managing patients with TOA.

Small bowel obstruction and perforation attributed to tubo-ovarian abscess following 'D' and 'C'

We report the case of a young woman who was admitted because of small bowel obstruction and localized peritonitis following a dilatation and curettage ('D’ and 'C’) of uterus in abortion. As infection, like tubo-ovarian abscess may complicate any abortion, it seems wise to ensure that it does not exist prior to performing a 'D’ and 'C’.

Tuboovarian Abscess due to Colonic Diverticulitis in a Virgin Patient with Morbid Obesity: A Case Report

Since tuboovarian abscess is almost always a complication of pelvic inflammatory disease, it is rarely observed in virgins. A 30-year-old virgin patient presented with pelvic pain, fever, and vaginal spotting for the previous three weeks. Her abdominopelvic computed tomography scan revealed bilateral multiseptated cystic masses with prominent air-fluid levels suggesting tuboovarian abscesses. The sigmoid colon was lying between two tuboovarian masses, and its borders could not be distinguished from the ovaries. The patient was presumed to have bilateral tuboovarian abscesses which developed as a complication of the sigmoid diverticulitis. She was administered intravenous antibiotic therapy followed by percutaneous drainage under ultrasonographic guidance. She was discharged on the twenty second day with prominent clinical and radiological improvement. Diverticulitis may be a reason for development of tuboovarian abscess in a virgin patient. Early recognition of the condition with percutaneous drainage in addition to antibiotic therapy helps to have an uncomplicated recovery.