A BIG OVARIAN CYST

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 July 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 on 5^th September 2024 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 transvaginal 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 started a 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, even when the patient cannot afford the cost of a CT scan.