SECTION EDITOR: CARL E. BREDENBERG, MD
Author Affiliations: Department of Surgery, Denver Health Medical Center, University of Colorado, Denver.
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.
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.
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.
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
Yi JA, Burlew CC, Barnett CC, Moore EE. Image of the Month—Quiz Case. Arch Surg. 2012;147(9):885–885. doi:10.1001/archsurg.2011.1283a