Failure of ultrasound to diagnose a giant ovarian cyst: a case report
© licensee BioMed Central Ltd. 2009
Received: 26 March 2009
Accepted: 9 July 2009
Published: 22 July 2009
Ultrasonography is the method of choice in the diagnosis of ovarian cysts. In this case report, a cyst of enormous volume (>35 litres) was limiting the application of ultrasound techniques giving the false impression of ascites. A 55-year-old woman was finally diagnosed as having a giant ovarian mucosal-serosal cystadenoma of borderline potential after undergoing a total abdominal hysterectomy with salpingo-oophorectomy and excision of the cyst. In the literature, similar conditions have been described with the term 'empty abdomen'.
Ovarian cysts rarely grow immense. Ultrasound scan examination permits early detection and appropriate treatment. Occasionally, ovarian cysts reach enormous dimensions without raising any symptom. A few cases of giant ovarian cysts have been sporadically reported in the literature -. Differential diagnosis with ascites is a major concern during the management of these cysts.
A case of a giant ovarian cyst mimicking ascites in a 59-year-woman is presented. Emphasis is drawn on the initial failure of ultrasound to assist in the diagnosis due to the enormous size of the cyst that hampered the application of ultrasound techniques.
Giant ovarian cysts mimicking ascites have been rarely reported in the literature. Similar conditions may arise from omentum, mesenterium, or retroperitoneal structures, and the differential diagnosis includes ascites, urinary retention, bladder diverticulum, hydronephrosis, pancreatic pseudocysts, and large uterine tumors -.
It is obvious from the history of the patient that initial sonographic approach failed to diagnose correctly the cyst. However, specific sonographic features that are pathognomonic of giant ovarian cysts were met after paracentesis of the cyst. First, the sonographic appearance of the intraperitoneal organs was highly suggestive of a giant growth. The liver was compressed just above the right kidney (and not free floating), a finding that contradicted to the diagnosis of free intraperitoneal fluid. The absence of other intraperitoneal structures, such as floating bowel loops within the abdomen, was another sign of a cystic mass repelling any other abdominal structure away. Second, the use of colour flow was highly suggestive of a neoplastic disorder appearing from the ovary. The colour flow is a sonographic feature that detects movement and is used in the vascular imaging and in producing Doppler waveforms. In the presented case, the colour flow detected a highly vascularised area within the lateral surface of the peritoneal wall. No normal intraoperative organs produce such an intense signal, so the presence of vasculature supplying a huge cyst, probably of ovarian origin, was further suspected. The combination of ultrasound techniques (morphologic assessment, color Doppler flow imaging, and Doppler indexes) have been found to perform well (sensitivity = 84%, specificity = 82%, positive likelihood ratio = 4.69) compared to computed tomography (sensitivity = 81%, specificity = 87%, positive likelihood ratio = 6.81) in the diagnosis of ovarian lesions . Computed tomography had similar findings to the ultrasound suggesting of an ovarian mass repelling the rest of the intraperitoneal organs. Clinical computed tomography images indicate that high accumulation of intraperitoneal fluid can increased the pressure and actually displaces bowel loops to one side of the abdomen and gives a compressed appearance (tense ascites). This is an atypical presentation of ascites that can be easily confused with a mass .
The sonographic features described above are pathognomonic of a giant ovarian cyst. The term 'empty abdomen' has been used to describe the sonographic appearance of similar conditions.
In conclusion, giant ovarian cysts should always be considered in the differential diagnosis of conditions such as ascites. Two dimensional ultrasound appears to be a cost-effective and accurate technique. The application of extra features such as the colour flow and the Doppler waveforms enhance its diagnostic accuracy. There are cases where drainage of such cysts helps in the application of the sonographic techniques, otherwise the volume of the cysts is a limit to the diagnostic sonographic approach.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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