A Woman with Lower Abdominal Pain

Posted by • October 27th, 2016

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Most ovarian abscesses that occur in patients in the Western world are associated with pelvic inflammatory disease and are preceded by involvement of the fallopian tube as part of an ascending bacterial infection. Direct extension from nongynecologic infections or hematogenous or lymphatic spread may occur less commonly. The absence of marked tubal involvement is uncommon. A 30-year-old woman presented to the hospital with abdominal pain, nausea, and chills. Evaluation showed tachycardia, bilateral lower-quadrant abdominal tenderness, leukocytosis, and an elevated CA-125 level. Imaging studies showed adnexal cysts. A diagnosis was made in a new Case Record article.

Clinical Pearl

Is abscess formation a common complication of endometriotic cysts?

Endometriosis and endometriotic cysts are commonly associated with a low-grade inflammatory response that is generally chronic. Acute inflammation with abscess formation is rare.

Clinical Pearl

What are some of the patient factors associated with an elevated CA-125 level?

As a large transmembrane glycoprotein derived from coelomic mesothelial cells (i.e., cells originating in the pericardium, pleura, or peritoneum) and müllerian epithelium (i.e., epithelium that lines the endometrium, endocervix, and fallopian tubes), CA-125 is a nonspecific marker for peritoneal inflammation. Many factors make an elevated CA-125 level unreliable for the screening and diagnosis of ovarian cancer, because many conditions can elevate the CA-125 level, and specific patient characteristics can raise and lower the level. For example, CA-125 levels are higher in premenopausal women and in women of African or Asian descent and lower in postmenopausal women, in women who smoke, and in women who have had a hysterectomy.

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Morning Report Questions

Q: How do isolated ovarian abscesses without tubal involvement differ from tubo-ovarian abscesses?

A: As compared with tubo-ovarian abscesses, ovarian abscesses without tubal involvement are frequently unilateral, with bilateral involvement present in only 20% of cases. In contrast to tubo-ovarian abscesses, which frequently involve the surface of the ovary, isolated ovarian abscesses are often unremarkable on the surface, and the abscess becomes apparent only on sectioning.

Q: What is known about the source of infection in cases of isolated ovarian abscesses?

A: An extensive body of literature exists regarding the types of infectious organisms associated with tubo-ovarian abscesses, with such abscesses attributed to Neisseria gonorrhoeae, Chlamydia trachomatis, mixed aerobic and anaerobic organisms that are reflective of normal vaginal or cervical flora, and, infrequently, mycobacteria. A less extensive body of literature exists regarding the causative agents in cases of isolated ovarian abscesses. Such cases have revealed a variety of causative organisms, including those found in the urinary, respiratory, or oropharyngeal and gastrointestinal tracts. A number of theories have been postulated with respect to the route of infection, including direct extension of a nongynecologic infection such as diverticulitis, appendicitis, or inflammatory bowel disease; hematogenous or lymphatic spread from a distant infection; and direct inoculation caused by procedural or operative manipulation of the ovary. Historically, the literature has focused on direct inoculation, with procedural and surgical manipulation being an obvious risk factor. Occasionally infection of a preexisting cyst may occur.

One Response to “A Woman with Lower Abdominal Pain”

  1. baahmed azzedine says:

    Thank you