{"paper_id":"d4651e11-b05b-4618-a13c-b3bcf37db0ff","body_text":"Journal of Clinical and Diagnostic Research. 2011 October, Vol-5(5): 1109-1110 11091109\nRuptured Endometrioma Presenting as \nAcute Abdomen with Highly Raised Serum \nCA-125 Levels: A Case Report\nKey Words: Endometriosis, Endometrioma, CA-125, Acute Abdomen, Peritonitis\nABSTRACT\nA 35 yr old lady, para 2, living 2, with 2 previous caesarean sec­\ntions, presented with the features of acute abdomen. The clinical \nand laboratory evaluations revealed a bilateral ovarian mass with \nsolid and cystic components, with raised serum CA­125 levels \nand raised ESR. The differential diagnosis included abdominal \nor genital tuberculosis, secondary carcinoma of the ovaries and \nendometriomas. This case is being reported and discussed in \ndetail, for which an emergency exploratory laporotomy was \nperformed. The intraoperative features suggested the diagnosis \nof spontaneous peritonitis which was secondary to ruptured b/l \novarian endometriomas.\nANAGHA KAMATH\nOBG & GYN Section\nCASE REPORT\nA 35yr old lady who hailed from Chikmagalur India, a labourer by \noccupation, para 2, living 2, with 2 previous 2 LSCS, presented on \nthe third day of her menstrual cycle, with complaints of abdominal \ndistension, nausea, vomiting, breathlessness since 2 days; low \ngrade, mild and intermittent fever since 1 month; oligomenorrhoea \nand lower abdominal pain which was mild and intermittent, since \n6 months. On examination, she was found to be afebrile, had \ntachypnoea and tachycardia, was normotensive; had normal \ncardiovascular and respiratory systems; her per abdomen had the \nfeatures of abdominal distension, guarding, rigidity, tenderness in \nthe right iliac fossa, shifting dullness and sluggish bowel sounds. \nThe per speculum examination revealed bleeding through the \nos with a normal vagina and cervix; her per vaginal examination \nrevealed a normal sized uterus, fullness in the right fornix and \npresence of the pouch of Douglas. Her per rectal examination \nconfirmed the fullness in the pouch of Douglas. \nOn further investigating, her blood tests showed leukocytosis of \n15,000, neutrophilia, ESR of 37, normal liver and renal function \ntests and urine pregnancy test was negative. The ultrasound \nof abdomen and pelvis depicted a bilateral adenexal mass  \nwith solid and cystic components, the right ovary measured \n7.4*3.4cm, there was fluid in the pouch of Douglas and ascites. \nThe serum CA-125 level was 1625units; her Beta human chorionic \ngonadotrophin level was 0.9units, and alpha feto protein AFP level \nwas 2.63 units.\nThe high CA-125 levels raised the suspicion of an ovarian malig-\nnancy. After taking clearance from the physician, the surgeon \nand the anaesthetist, an emergency exploratory laporotomy was \nperformed, wherein the chocolate coloured fluid was drained from \nthe peritoneal cavity and sent for cytology. Her bowel exploration \nrevealed no abnormality and she had a left ovarian mass of \n7*6cm and a right ovarian mass of 4*3cm. Adhesions were also \npresent in her uterus, urinary bladder and rectum. The adhesions \nwere released, a total abdominal hysterectomy with bilateral \nsalpingo oophorectomy was done and the tissues were sent for \nhistopathological studies to the Department of Pathology, Kasturba \nMedical College, Mangalore.\nHISTOPATHOLOGY \nThe histopathological studies reported features which were \nsuggestive of endometriomas. The ascitic fluid was negative for \nmalignant cytology.\nDISCUSSION\nEndometriosis is defined as the presence of endometrial glands \nand stroma outside the normal location, which are most commonly \nfound in the pelvic peritoneum, but may also be found in the \novaries, the rectovaginal septum and the ureters, but rarely in the \nbladder, the pericardium and the pleura. Endometriomas are the \ncystic endometrial lesions which are contained within the ovaries. \nThe spontaneous rupture of an endometriotic cyst is very rare. Very \nfew cases have been reported till now and most of them have been \nassociated with pregnancy [1]. The rupture of an endometriotic \ncyst is one of the representative acute gynaecological disorders \nwhich are manifested by acute abdominal pain and inflammatory \nreactions [2]. This frequently induces elevations in the body temp-\nerature, the WBC count and the serum CRP levels, all of which \nare acute inflammatory reactions. These inflammatory responses \nare considered to be induced by the content of an ovarian \nendometriotic cyst. Since abdominal pain is a major symptom in \nthis case, the differential diagnosis from any underlying intestinal \ndisease is often necessary, and infectious diseases in the adnexa \nshould also be ruled out. \nIn our present case report, a 35yr old lady presented with chronic \nsymptoms of 6 months duration, which was superimposed by an \nacute abdomen of 2 days duration. Acute abdominal pain, with a \nhistory of fever, with a guarding rigidity with leucocytosis, suggested \nperitonitis. Clinically, the differential diagnosis included abdominal \nor genital tuberculosis, carcinomas in the gastro-intestinal system \nor in the ovaries and endometriomas.\nThe investigations revealed leukocytosis, raised ESR, very high \nserum CA-125(1625IU/ml) levels, bilateral ovarian masses with \nascites which pointed out more towards the secondaries in the \novaries or ruptured chocolate cysts with peritonitis or peritonitis \nwhich was secondary to bowel perforation. Intraoperatively, the \nfeatures of a chocolate to brownish coloured fluid in the peritoneum \nCase Report\n\nAnagha Kamath, Ruptured Endometrioma www.jcdr.net\nJournal of Clinical and Diagnostic Research. 2011 October, Vol-5(5): 1109-111011101110\nand the bilateral ovarian cysts clearly suggested the diagnosis of \nspontaneous peritonitis which was secondary to ruptured, bilateral \novarian endometriomas with raised serum CA-125 levels.\nSerum CA 125 is the gold standard tumour marker for the evaluation \nof pelvic masses. Distinguishing the benign conditions from the \nmalignant standard cut off of 35 IU /ml (the normal range being 0 \n-35 IU/ml) can be misleading, especially in menstruating women \nand hence, a cut off from 65 to 200 IU /ml is necessary. The levels \nof CA-125 which are > 65 U/mL, correlate highly with ovarian \nmalignancies and distinguish the malignant diseases from the \nbenign diseases, with a specificity of 88 to 92% and a sensitivity of \n75% to 83% [1]. Plasma CA-125 levels which are > 194 U/mL are \nconsidered as a positive criterion for differentiating the malignant \npelvic masses from the benign pelvic masses [2]. \nSerum CA-125 measurement is now a consolidated method \nfor diagnosing endometriosis, but its interpretation has posed a \nnumber of problems, particularly its utility in diagnosing minimal-\nmild endometriosis, whereas its value as a diagnostic aid in the \nmoderate-severe stages is well recognized. The serological testing \nfor CA125 has been widely used not only to detect endometriosis, \nbut also to monitor its progression [3] [4]. The patients with endo-\nmetriosis rarely have CA-125 levels which are >100 IU/ ml. However, \nendometriosis constitutes a major non-malignant gynaecological \ndisease wherein the serum CA-125 levels are in the malignancy \nrange (>1,000 IU/ml) [5]. The severity of endometriosis has been \nshown to be positively correlated with elevated CA-125 levels. \nSerum CA-125 is significantly elevated with respect to the ovarian \nand mixed endometriosis lesions in comparison with the exclusive \nextraovarian foci [6].\nThe CA-125 levels are reported to rise immediately after the \nrupture of an endometriotic cyst and also following malignant \ntransformation [7]. An explosive rise of the serum CA-125 levels to \nup to 9300 IU/ ml following the rupture of ovarian endometrioma \nhas been reported [8]. The sudden release of endometriotic cyst \nfluids containing very high concentrations of CA-125, combined \nwith pelvic peritoneal irritation, may contribute to the unusual rise \nof the serum CA-125 levels. This is the highest value which has \nbeen reported so far with histologically confirmed endomertiosis. \nHowever, Kahraman A et al reported a 25-year-old woman with \nunruptured unilateral endometrioma and stage IV endometriosis, \nwith extremely elevated serum CA-125 levels of 7,900 U/mL [9].\n \nThis case demonstrated that abnormally high levels of plasma CA-\n125 may be encountered in large ovarian endometriomas without \nrupture and without the overflow of the thick, “chocolate” cyst fluid \nthroughout the abdominal cavity. Chii-Shinn Shiau et al reported \nCA125 levels of 6310 IU/ ml with an unruptured endometioma [10]. \nThe consensus conference recommendations from an expert  \npanel of gynaecologists in the US stated that hysterectomy with \nbilateral salphingo oophorectomy. BSO, which was reserved for \nfemales with symptomatic endometriosis, completed child bearing \nand recognized the risk of premature hypo-oestrogenism, including \npossible osteoporosis and decreased libido [11], which justifies our \nmanagement in this case. \nCONCLUSION\nOvarian endometrioma and endometriosis may present acutely and \nthey may be associated with extremely elevated serum CA-125 \nlevels. For this reason, ovarian endometrioma should be considered \nwith respect to the differential diagnosis of reproductive-age women \nwho present with an acute abdomen and an ovarian mass, even \nif it resembles an ovarian malignancy. Moreover, very high CA-125 \nlevels do not necessarily forebode an ovarian malignancy.\nACKNOWLEDGEMENT\nI acknowledge the surgical and nursing staff of Wenlock and Lady \nGoshen Government Hospitals, Mangalore; and the Department of \nPathology, Kasturba Medical College, Mangalore, without whose \nhelp this work would not have been possible. The unyielding \nsupport of the patient and her family has always been with me.\nREFERENCES\n [1] Garcia Verasco JA , Alvarez M, Parumbo A et al. Rupture of an \nendometrioma during the first trimester of pregnancy. Eur J Obstet \nGynecol Reprod Biol 1998; 76:41-43.\n [2] Pratt JH, Shamblin WR . The spontaneous rupture of the endometrial \ncysts of the ovary which presented as an acute abdominal emergency. \nAm. J. Obstet. Gynecol 1970; 108: 56–62.\n [3] Cheng YM, Wang ST, Chou CY. Serum CA-125 in preoperative \npatients who are at a high risk for endometriosis. Obstet Gynecol. \n2002; 99 (3):375-80.\n [4] Rosa E Silva AC, Rosa E Silva JC, Ferriani RA. Serum CA-125 in the \ndiagnosis of endometriosis. Int J Gynaecol Obstet. 2007; 96:206-7. \n [5] He RH, Yao WM, Wu LY, Mao YY. Highly elevated serum CA-125 levels \nin patients with non-malignant gynecological diseases. Arch Gynecol \nObstet. 2011;283:107-10.\n [6] Patrelli TS, Berretta R, Gizzo S, Pezzuto A, Franchi L, Lukanovic A et \nal.CA 125 serum values in surgically treated endometriosis patients \nand their relationship with the anatomic sites of endometriosis and the \npregnancy rate. Fertil Steril 2011; 95:393-6. \n [7] Check JH. CA-125 as a biomarker for the malignant transformation \nof endometriosis. Fertil Steril. 2009; 91:e35; author reply e36. Epub \n2009 Mar 31.\n [8] Johansson J, Santala M, Kauppila A. The explosive rise of serum CA \n125 following the rupture of ovarian endometrioma. Hum. Reprod \n1998; 13:3503–3504. \n [9] Kahraman K, Ozguven I, Gungor M, Atabekoglu CS. Extremely \nelevated serum CA-125 levels as a result of unruptured unilateral \nendometrioma: the highest value reported. Fertil Steril. 2007; 88: 968.\n[10] Shiau CS, Chang M Y, Chiang CH, Hsieh CC, Hsieh TT. Ovarian \nendometrioma which was associated with very high serum CA-125 \nlevels. Chang Gung Med J 2003; 26:695-699.\n[11] Gambone J C, Mittman B S, Munro M G,Scialli AR,Winkel CA et al. A \nconsensus statement for the management of CPP and endometriosis. \nProceedings of an expert panel process. Fertil Steril 2002; 78:961.\nAUTHOR(S):\n1. Dr. Anagha Kamath\nPARTICULARS OF CONTRIBUTORS:\nAssistant Professor, Department of Obstetrics and Gynaecology\nKasturba Medical College, Mangalore.\nNAME, ADDRESS, TELEPHONE, E-MAIL ID OF THE \nCORRESPONDING AUTHOR:\nDr. Anagha Kamath, Assistant Professor\nDepartment of Obstetrics and Gynaecology,  \nKasturba Medical College, Behind Leo Furnitures,\nKarangalpady, Mangalore.\nDECLARATION ON COMPETING INTERESTS:  \nNo competing Interests.\nDate of Submission: May 05, 2011  \nDate of peer review: Jul 19, 2011 \nDate of acceptance: Jul 29, 2011\nOnline first: Aug 24, 2011\nDate of Publishing: Oct 05, 2011","source_license":"CC0","license_restricted":false}