CASE REPORT

A 70-year-old female patient was admitted in our hospital for severe
abdominal distention. She complained about a progressive increase of
abdominal volume since several months before. She was admitted for the
first time in April 2023 and was discharged after 22 days with
diagnosis of "ascites and suspect of multiple liver masses". During
that admission an abdominal tapping was performed draining 2 liters of
cloudy fluid with high viscosity. A sample was sent for cytology, the
cytology result read: "interpretation of this specimen is made
difficult by the fact that some autolysis has taken place but shows
macrophages and chronic inflammatory cells". The laboratory
investigations didn't show any significant alteration and the general
conditions were quite good. The provisional diagnosed was of liver
cirrhosis, and she was discharged on treatment with a high dose of
diuretics.
She came back in early July still complaining of abdominal
distention, which was asymptomatic; her blood pressure was 100/60
mmHg, the general conditions quite good. There was no jaundice, nor
edema of the lower limbs, nor lung crackles. The heart activity was
normal. Visiting the patient we have noticed the presence of huge
abdominal distension, which was tender; there was also evidence of
collateral veins on the abdominal wall. The percussion of the abdomen
was dull as in presence of fluid or masses, while the intra-abdominal
organs were not explorable. The laboratory investigations were almost
normal: FHG showed a mild microcytic anaemia (Hb 8,8 g/dl), LFTs were
in range, kidney function tests were normal, while serologies for
hepatitis B, C and HIV were negative. ESR was103 mm/hr. A first U/S
was performed, where the abdominal organs weren't well seen because of
the big quantity of corpuscolated fluid, while multiple round masses
in the abdomen were appreciated.
At trans-vaginal U/S the uterus was normal, the ovaries not seen due
to the presence of big quantity of intra-abdominal fluid. Considering
the previous diagnosis of liver cirrhosis we continued treatment with
high doses of frusemide and spironolactone; at the same time, on the
day of admission, we tried to perform an abdominal tapping: to our
surprise we managed to drain only 200 ml of a cloudy, very thick and
sticky fluid. We repeated the tapping 2 days later, this time draining
600 ml of fluid with the same aspect. We increased the amount of
fluids and reduced the dosage of diuretics, but a third tapping showed
the same kind of fluid that was impossible to drain because of its
thickness.
We decided to repeat the US with the help of a more expert doctor and
we were surprised to understand that all this fluid wasn't ascites at
all, but rather fluid inside a giant ovarian cyst reaching up to the
diaphragm. The US image didn't show the bowel loops "swimming" inside
the anecoic fluid as it is normally the case in ascites; on the
contrary the bowel loops were pushed back by the big ovarian mass. A
surgical operation was performed few days after and a giant ovarian
cyst with multiple daughter-cysts was excised. The biopsy showed a
benign ovarian cystoadenoma: in the differential diagnosis there was
of course a malignancy of the ovary but also a hydatid cyst.
The post-operative follow up was normal and the patient was discharged
without any further complication.
The learning point we can draw from this clinical case is the
importance of US in the management of patients in a resource
constrained setting. The US is a very important instrument to help in
diagnosis and treatment of many different conditions; a correct
interpretation of US imaging can significantly reduce the
indiscriminate use of drugs based only on the clinical appearance of
the patient, and it plays a pivotal role in deciding the need of an
operation.