A Tubo-ovarian Abscess Identified via Colonoscopy

A tubo-ovarian abscess (TOA) is an inflammatory mass involving the fallopian tube and ovary and may extend to the surrounding structures. We present a case of a TOA manifesting as a mucosal defect with intraluminal drainage seen on colonoscopy. A 44-year-old female presented with one month of fevers, chills, left lower quadrant abdominal pain, and 10-20 daily episodes of small volume diarrhea with passage of mucous. She had been admitted to the psychiatry unit for a month due to depression and anxiety secondary to the recent suicide of her daughter. Diarrhea had persisted since her admission. However, upon discharge, she began to have fevers and chills. She had no history of sexually transmitted infections but had an intrauterine device removed at the onset of her symptoms. A CT scan showed a large, complex left ovarian mass involving the rectum and sigmoid with thickening of the colon from the rectum to the transverse colon suggestive of colitis. Due to concern for malignancy, she underwent a colonoscopy, which revealed extrinsic compression of normal sigmoid mucosa and two 2 mm punctate mucosal defects in the sigmoid colon. During careful examination with insufflation, the defects excreted opaque, exudative material. She underwent exploratory laparotomy, modified radical hysterectomy, bilateral salpingo-oophorectomy, and rectosigmoid resection with end-to-end anastomosis. A left-sided fixed mass from ovary to rectosigmoid expressing purulent material was seen with normal appearing bowel. Colon histology showed acute and chronic inflammation and fibrosis of the serosa, muscularis propria, and submucosa with unremarkable mucosa. Ovarian pathology showed acute and chronic inflammation and granulation tissue consistent with a ruptured TOA. Cytology was negative for malignant cells. She was treated with parental antibiotics and made an unremarkable recovery. A TOA is a severe complication of pelvic inflammatory disease (PID). Mortality is low prior to rupture and historical data suggests that mortality from a ruptured TOA may be from 1.7-3.7%. PID may be associated with insertion of an IUD, but rarely with removal. 60-80% of TOA may resolve with antibiotics, but surgery is indicated for ruptured abscesses. Anatomic proximity to the sigmoid colon allows direct involvement with the potential for colonic perforation, fistula formation, or diverticulitis.Figure 1Figure 2Figure 3