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OpenAthens Shibboleth
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Special Feature
Sep 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, Denver Health Medical Center, University of Colorado, Denver.

Arch Surg. 2012;147(9):885-885. doi:10.1001/archsurg.2011.1283a

A 53-year-old woman had abdominal pain, nausea, vomiting, and obstipation for 4 days. Her medical history was significant for bipolar disorder, schizophrenia, total abdominal hysterectomy after a complicated birth, and right oophorectomy for a hemorrhagic cyst. She was being followed up by the gynecology service as an outpatient for a left adnexal mass and was on their elective operative schedule for resection for a presumed ovarian malignant neoplasm. On examination, she had abdominal distention and was tender to palpation in the left lower quadrant. Her laboratory analysis findings, including a complete blood cell count and metabolic panel, were normal aside from elevated levels of CA 19-9 (35 U/mL), carcinoembryonic antigen (58.3 ng/mL; to convert to micrograms per liter, multiply by 1.0), and cancer antigen 125 (62 U/mL; to convert to kilounits per liter, multiply by 1.0). A computed tomographic scan of the abdomen revealed a complex cystic and solid pelvic mass measuring 13 × 15 cm, diffuse retroperitoneal lymphadenopathy, and cecal distention with a pedunculated area of mural enhancement in the transverse colon measuring 2 cm but no obvious obstructing colonic mass (Figure 1 and Figure 2). The gastroenterology service was consulted and declined to perform colonoscopy owing to a presumed inability to prepare the bowel.

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Figure 1. Computed tomographic scan (sagittal view) revealing a complex pelvic mass and right colonic distention. F indicates feet; H, head; L, left, and R, right.

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Figure 2. Computed tomographic scan (coronal view) of the pedunculated colonic mass (arrow). A indicates anterior; L, left, P, posterior; and R, right.

The patient was taken to the operating room and found to have a left adnexal mass as well as an intraluminal mass in her transverse colon with significant associated mesenteric lymphadenopathy. Mass resection, left salpingo-oophorectomy, and an extended right hemicolectomy with lymphadenectomy were performed.

What Is the Diagnosis?

A. Perforated large-bowel obstruction with pelvic abscess

B. Primary colorectal carcinoma with ovarian metastasis

C. Synchronous colorectal and ovarian carcinoma

D. Ovarian carcinoma with direct mechanical colonic obstruction