{"paper_id":"4157933a-d37c-4dbc-822d-1baa9f4c9352","body_text":"Review began\n 01/01/2024 \nReview ended\n 01/18/2024 \nPublished\n 01/29/2024\n© Copyright \n2024\nMohd Hanapiah et al. This is an open\naccess article distributed under the terms of\nthe Creative Commons Attribution License\nCC-BY 4.0., which permits unrestricted use,\ndistribution, and reproduction in any\nmedium, provided the original author and\nsource are credited.\nComputed Tomography Findings in a Case of\nUterine Rupture as a Complication of Pyometra\nFadhila Mohd Hanapiah \n \n, \nZul Khairul Azwadi Ismail \n \n, \nOthman Puteh \n \n, \nMohd Ezane Aziz \n1.\n Radiology, Universiti Sains Malaysia School of Medical Sciences, Kubang Kerian, MYS\nCorresponding author: \nZul Khairul Azwadi Ismail, \nzul.wadi@usm.my\nAbstract\nUterine rupture in the setting of pyometra is a rare occasion, with an incidence of less than 0.5%. The\nclinical manifestation of a perforated pyometra is non-specific; therefore, it can mimic many other causes\nof acute abdomen, such as perforated viscus, acute appendicitis, or diverticulitis, which poses unique\nchallenges to diagnosis solely based on clinical information. We reviewed a case of an elderly\npostmenopausal lady who presented with a sudden onset of generalized abdominal pain, preceded by fever\nand vomiting. Physical examination revealed a distended abdomen with clinical signs of peritonism. She was\ninitially diagnosed with possible obstructed gastrointestinal carcinoma by clinical examination, with the\ndifferential diagnosis of diverticular abscess. Eventually, further abdominal and pelvic contrast-enhanced\ncomputed tomography (CECT) study revealed a pyometra with uterine rupture, complicated with\npneumoretroperitoneum and pneumoperitoneum. This case emphasizes the value of a CT scan in\nestablishing an accurate diagnosis and early detection of life-threatening complications, such as uterine\nrupture, as in this case.\nCategories:\n Obstetrics/Gynecology, Radiology\nKeywords:\n pneumoretroperitoneum, pneumoperitoneum, pyometra rupture, uterine rupture, pyometra\nIntroduction\nPyometra refers to a collection of pus within the uterine cavity. Spontaneous rupture of pyometra is a rare\noccurrence, with an incidence of only 0.01 - 0.05% \n[1]\n in patients presented with gynaecological causes of\nabdominal pain. It has been estimated that mortality from spontaneous perforation of pyometra is more\nthan 40%. It is commonly associated with pre-existing uterine diseases ranging from benign causes to\ngynaecological malignancy. The clinical manifestation of a perforated pyometra is non-specific and may\nmimic any other causes of an acute abdomen with peritonism such as perforated viscus, acute appendicitis,\nor diverticulitis, which poses unique challenges to diagnosis solely based on clinical information.\nUltrasonography is the first-line imaging modality for the evaluation of pyometra. However, it has a limited\nrole in cases of perforation due to the presence of air casting acoustic shadowing on the deeper pelvic or\nabdominal structures. Therefore, further assessment with a cross-sectional imaging modality, such as CT\nscan, is required. Fast and accurate pre-operative diagnosis of perforated pyometra is essential for surgical\nplanning and early intervention to reduce morbidity and mortality. To the best of our knowledge, several\ncases of perforated pyometra have been reported in the English literature, but only a few were diagnosed\npre-operatively \n[1,2,3]\n. Here, we report a very rare case of uterine rupture secondary to pyometra that was\ndiagnosed pre-operatively by a CT scan imaging.\nCase Presentation\nA 75-year-old postmenopausal lady presented to the emergency department with an acute onset of\ngeneralized abdominal pain, preceded by fever for 2 days and associated with vomiting. The pain was dull\naching in nature, and aggravated by movement. The patient claimed she was still able to pass flatus, had no\nepisode of altered bowel habits, and denied any family history of malignancy. She was medically treated for\nbronchial asthma, hypertension, and hyperlipidaemia, with no history of surgery. On clinical examination,\nthe abdomen was distended with generalized tenderness and guarding. A vague mass was palpable in the\nlower abdomen. She appeared ill-looking with vital signs as follows: blood pressure 108/63 mmHg, heart\nrate 115 beats/min, oxygen saturation 97% under room air, and a documented body temperature of 39\no\nC.\nThe initial blood investigation revealed a high total white count of 29x10\n9\n/L. She was put on 3 pints of\nnormal saline for IV drip maintenance and started on a combination of intravenous antibiotics cefoperazone\nand metronidazole. The case was initially referred to the surgical team with the diagnosis of a possible\ngastrointestinal malignancy with partially obstructed sigmoid carcinoma with the differential diagnosis of\ndiverticulitis. The patient was admitted to the surgical ward; however, her condition deteriorated with\nrespiratory distress, requiring ventilatory support in the ICU. The provisional diagnosis at that time was\nsepsis secondary to intra-abdominal collection. The case was then referred to the obstetrics and gynaecology\n(O&G) team to rule out any gynaecological causes. \n1\n1\n1\n1\n \n Open Access Case\nReport\n \nDOI:\n 10.7759/cureus.53154\nHow to cite this article\nMohd Hanapiah F, Ismail Z, Puteh O, et al. (January 29, 2024) Computed Tomography Findings in a Case of Uterine Rupture as a Complication of\nPyometra. Cureus 16(1): e53154. \nDOI 10.7759/cureus.53154\n\nTrans-abdominal ultrasound (TAS) assessment demonstrated a bulky uterus with irregular endometrial\nlining and intra-uterine collection. Free fluid was also seen surrounding the uterus. A CT scan of the\nabdomen and pelvis (refer Figure \n1\n) revealed a distorted uterus and the presence of an ill-defined hypodense\ncollection within the uterine cavity with bilateral parametrial fat stranding. There were multiple air pockets\nwithin the collection and foci of calcification within the uterine wall. There was a focal area of discontinuity\nat the uterine fundus in keeping with uterine rupture. Pockets of air and fluid collection with density similar\nto the intrauterine collection were seen within the pelvic cul-de-sac, which further confirmed the presence\nof a perforation. The CT scan also showed findings of pneumoperitoneum and pneumoretroperitoneum,\nwhich could indicate disruption of the peritoneal lining adjacent to the uterus. Moderate ascites was also\nobserved.\nFIGURE\n 1: Contrasted CT images\nSagittal reformatted CECT scan of the abdomen and pelvis showed an ill-defined hypodense collection (white\narrow) within the uterine cavity with multiple air pockets (A), axial sections of the pelvis demonstrated focal uterine\nwall discontinuity (black arrow) at the fundus consistent with rupture (B), presence of pneumoperitoneum\n(arrowhead) (C) and intra-abdominal free-fluid (thin arrow) (D).\nA total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAHBSO) was performed. The\nintraoperative findings revealed gross peritoneal contamination involving both subphrenic spaces,\nsubhepatic space, bilateral paracolic gutters, and pelvic cavity. Slough and pus were seen disseminated all\nover the peritoneal cavity with associated interloop collection. An area of perforation was observed at the\nuterine fundus, measuring about 1.0cm x 2.0cm, with discharging pus noted through the opening. The\nuterus was then cut open, disclosing foul-smelling pus and necrotic tissues within the endometrial cavity,\nwhich were then evacuated. A total of 600cc of pus was removed from the peritoneal and endometrial\ncavities followed by peritoneal lavage with copious amounts of saline, amounting to 12 litres.\nHistopathological study revealed uterine abscess, with no evidence of malignancy. However, pus culture and\nsensitivity taken identified \nEscherichia coli\n within the sample.\nThe surgery had an excellent outcome and the patient was able to gradually recover from septicaemia. She\nspent almost 3 weeks in the ICU, and then was allowed to be transferred to the general ward. She was\ndischarged on postoperative day 52 with only 1 complication of surgical wound breakdown. \nDiscussion\nPyometra, or the collection of purulent material within the uterine cavity, is essentially an extremely rare\ncondition. It is often associated with cervical stenosis or blockage, preventing the natural drainage of\nuterine secretion \n[4]\n. It is typically associated with postmenopausal women or those with underlying uterine\nmalignancy in most of the cases. Several other aetiologies include endometritis, pelvic inflammatory\ndisease, prior cervical surgery, pelvic irradiation, or retained intra-uterine contraceptive device (IUCD).\nHowever, in our case, no definite identifiable cause is found. There was no evidence of malignancy intra-\n2024 Mohd Hanapiah et al. Cureus 16(1): e53154. DOI 10.7759/cureus.53154\n2\n of \n4\n\noperatively, and she had no prior endometrial biopsy or dilatation curettage procedure. \nNevertheless, the most probable cause might be due to post-menopausal changes and cervical stenosis\ncausing degenerative changes of the uterine wall \n[5]\n, characterized by sloughing of the uterine wall that\nleads to stagnation of discharge, resulting in anaerobic infection causing perforation at the fundus.\nCommonly isolated organisms from pyometras include\n Streptococcus\n species, \nBacteroides fragilis\n,\nand \nEscherichia coli \n[6,7]\n. In our case, \nE. coli\n has been identified as the culprit. \nE. coli\n is a normal intestinal\ncommensal that can also colonize the vaginal microbiota. It can also be highly pathogenic to the\nreproductive system when present in abundance. It is a highly virulent micro-organism that can cause\nendometritis, septicaemia, and uterine necrosis, which necessitates definitive surgical intervention to\nachieve the resolution of the infection. The organism likely has caused inflammation and weakening of the\nuterine tissues. As the integrity of the uterine wall has been affected, the potential risk of rupture is\ninevitable.\nConclusions\nThe clinical findings of perforated pyometra usually mimic gastrointestinal tract perforation, posing\nchallenges to clinicians to arrive at an accurate diagnosis pre-operatively. Conventionally, the diagnosis is\nreached by exploratory laparotomy. The role of transabdominal ultrasound is limited due to the presence of\nair, and it has low sensitivity to detect small perforations. CT scan is indispensable in reaching an accurate\ndiagnosis and location of the perforation by exhibiting a focal area of uterine wall discontinuity. Although\nspontaneously perforated pyometra is a rare entity, the condition must be considered when dealing with\npostmenopausal women with acute abdominal pain with clinical manifestations of peritonitis. Awareness of\nrisk factors can contribute to the prevention and early detection of conditions that may lead to pyometra in\norder to mitigate the risk of uterine rupture. A prompt diagnosis with early intervention is proven to save\nlives from this catastrophic complication of pyometra.\nAdditional Information\nAuthor Contributions\nAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of the\nwork.\nConcept and design:\n  \nFadhila Mohd Hanapiah, Zul Khairul Azwadi Ismail, Othman Puteh\nAcquisition, analysis, or interpretation of data:\n  \nFadhila Mohd Hanapiah, Mohd Ezane Aziz\nDrafting of the manuscript:\n  \nFadhila Mohd Hanapiah\nCritical review of the manuscript for important intellectual content:\n  \nZul Khairul Azwadi Ismail,\nOthman Puteh, Mohd Ezane Aziz\nSupervision:\n  \nZul Khairul Azwadi Ismail, Othman Puteh, Mohd Ezane Aziz\nDisclosures\nHuman subjects:\n Consent was obtained or waived by all participants in this study. \nConflicts of interest:\n In\ncompliance with the ICMJE uniform disclosure form, all authors declare the following: \nPayment/services\ninfo:\n All authors have declared that no financial support was received from any organization for the\nsubmitted work. \nFinancial relationships:\n All authors have declared that they have no financial\nrelationships at present or within the previous three years with any organizations that might have an\ninterest in the submitted work. \nOther relationships:\n All authors have declared that there are no other\nrelationships or activities that could appear to have influenced the submitted work.\nReferences\n1\n. \nKim J, Cho DH, Kim YK, Lee JH, Jeong YJ: \nSealed-off spontaneous perforation of a pyometra diagnosed\npreoperatively by magnetic resonance imaging: a case report\n. 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