A patient with a rupture of cystic adenomyosis who underwent enucleation by laparoscopy for acute abdomen

Cystic adenomyosis, which leads to a relatively rare clinical condition wherein a cyst is formed by repeated local hemorrhage from endometriosis of the myometrium, presents a difficulty in preoperative diagnosis. We report a case of a patient who was diagnosed with rupture of cystic adenomyosis using laparoscopic surgery. Case: The patient was a 31-year-old nulliparous, nulligravid woman. Her past medical history was unremarkable. Her menstrual cycle was regular, occurring every 28–30 days. She visited the emergency department with a chief complaint of lower abdominal pain on the eighth day of her menstruation. Because a mass was found at the left adnexal region on computed tomography scan, she was suspected of having a gynecologic disorder and was referred to our hospital. At initial examination in our hospital, the patient had tenderness in the whole abdominal region. Transvaginal ultrasound sonography revealed that she had an 8-cm myoma and a 6-cm mass with an irregular border located at the left adnexal region. The mass was near the left ovary, and this matched the area with direct and rebound tenderness. Magnetic resonance imaging revealed a 6-cm mass with an irregular border with low-signal intensity, including partial and fairly high-signal intensities and mixed areas of high- and low-signal intensities on T1- and T2-weighted imaging, respectively. The imaging showed normal-sized bilateral ovaries. Based on the clinical course and image findings, subserosal myoma volvulus was suspected, and emergency laparoscopic surgery was performed. A large amount of clot was observed in the abdominal cavity. The bilateral adnexae were normal, whereas myoma-like masses were found in the uterus. One of these masses projecting from the anterior wall of the uterus ruptured with continuous hemorrhage. The mass was excised from its base through transection using an ultrasonic coagulation device. Histopathologic examination findings showed a mass with hemorrhage; the cystic wall showed zonal endometrioid glandular epithelia and interstitial changes. Smooth muscle bundles were found around the wall. Thus, this patient was diagnosed with a rupture of cystic adenomyosis. The postoperative course was good, and she was discharged five days after surgery.

As a rare example of a rupture of cystic adenomyosis, which was difficult to diagnose, we treated a patient with acute abdomen using laparoscopic surgery. Although rare, we think that a rupture of cystic adenomyosis should be considered as a cause for an acute abdomen. © 2016 日本産科婦人科内視鏡学会