Tubo-Ovarian Abscess Presenting as Pneumoperitoneum

Background: Tubo-ovarian abscess (TOA), a serious complication of pelvic inflammatory disease, often require the antibiotic administration, surgical resection or the transvaginal aspiration. Pneumoperitoneum is often associated with the bowel perforation. We reported one case with TOA and pneumoperitoneum that have been mistaken for a perforated bowel with concomitant adnexal mass. Case: A 30-year-old diabetic Chinese woman was transferred for diffused abdominal pain, mild fever, nausea, and low-grade fever for 5 days. The sonography revealed a 5-cm adnexal mass. The chest X-rays revealed the pneumoperitoneum. Under the impression of bowel perforation and concomitant adnexal cyst, the emergent laparotomy was performed and the TOA was resected. No evidence of gastrointestinal perforation was present. Culture studies showed Escherichia coli without other bacteria flora. The postoperative course was uneventful. Conclusion: We concluded that, beside the bowel perforation, TOA should be considered when a diabetic woman presents with pneumoperitoneum and adnexal mass.     

Intrauterine incarcerated bowel following uterine perforation during an abortion: a case report

The case of small bowel incarcerated within the uterine cavity following a legal abortion is presented. The case, a 26-year old woman, gravida 5, para 4, was aborted with a rigid-type plastic suction cannula at 13 weeks after her last menstrual period. During the 1st hour after the procedure, the patient developed severe abdominal pain and vomiting. The uterus was felt to be 18 weeks in size, firm, and tender. Sonographic examination revealed multiple well-defined round cystic structures within the uterine cavity. At laparotomy, incarcerated and partially gangrenous small intestine was found in an intrauterine location. The perforation had occurred in the anterior fundal region, distant from the uterine scars from the case's 4 previous cesarian sections. This case illustrates a rare and serious complication of abortion and demonstrates the utility of sonography in postprocedure symptomatic patients. No other such cases have been reported in the literature.     

Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review

Objective

Small bowel obstruction after unrecognized or conservatively treated uterine perforation is extremely rare. It is a surgical emergency and the delay in diagnosis and treatment has deleterious consequences for the mother. The purpose of this study is to critically review the available literature and ascertain the level of evidence for the mechanisms, diagnosis and management of small bowel obstruction after uterine perforation due to surgical abortion.

Methods

Systematic literature search was conducted in Pubmed (1946 to 2012) and Pubmedcentral (1900 to 2012) including all available English and French language fulltext articles. Three evaluators reviewed and selected all available case reports and case series. Search terms included small bowel obstruction, bowel obstruction, bowel incarceration, bowel entrapment, vaginal evisceration, uterine perforation, uterine rupture, and abortion. The exclusion criteria were (1) complex injuries where small bowel incarceration was present but with bleeding and/or bowel perforation as the leading symptomatology; (2) articles only numbering the patients without details on the topic. Analyses of incidence, risk factors, mechanisms of the disease, time of clinical presentation, diagnostic modalities, treatment, and maternal outcome were included.

Results

Of the 73 articles screened 30 cases of small bowel obstruction were included in the review forming incidence, risk factors, and mechanisms of the disease, diagnosis, therapy, and maternal outcome.

Conclusions

A systematic review defined four mechanisms of small bowel obstruction after transvaginal instrumental uterine perforation with significant variations in clinical presentation and time of presentation. Duration of symptoms depend on the mechanism of small bowel obstruction. Vaginal evisceration is surgical emergency and treatment is mandatory without diagnostic workup. Survival rate during last century is 93 %. Multicentric trials and publication of all such cases are needed to determine algorithms for diagnosis and management of small bowel obstruction caused by instrumental uterine perforation.     

Migration of an Intrauterine Contraceptive Device during the Course of Pregnancy: A Case Report

Uterine perforation by a contraceptive intrauterine device (IUD) is a relatively rare event. These events may result secondary to mechanical force applied during placement (primary perforation) or migration by uterine contractions or surgical manipulation after placement (secondary perforation). A 33-year-old woman with an IUD placed 9 years before admission visited the emergency department with an early pregnancy and a 3-day history of vaginal bleeding. Vaginal examination revealed IUD strings visible at the cervical os, and transvaginal ultrasound confirmed the presence of an IUD in the lower uterine segment and upper cervix. The IUD migrated spontaneously to the fundal myometrium at 15 weeks’ gestation. Premature rupture of membranes ensued at 20 weeks’ gestation, and, at delivery, the IUD could not be retrieved. Subsequent computed tomography confirmed that the IUD was incompletely embedded in the fundal myometrium and partially extending into the peritoneal cavity. At laparoscopic sterilization 6 weeks later, the IUD had perforated the small bowel, and the device was removed with concomitant bowel repair. This case documents spontaneous migration of a copper IUD from the lower uterine segment through the fundus during early pregnancy and supports removal of asymptomatic ectopic IUDs whenever possible.     

Difficulties associated with removal of mesh eroding into vagina following abdominal sacrocolpopexy: a case report

This case report describes the clinical case of a patient presenting complications during removal of mesh eroding through the lower one third of the posterior vaginal wall following abdominal sacrocolpopexy. Although excellent results have been reported with abdominal sacrocolpopexy for treatment of vaginal vault prolapse, minimizing complications and their correction remains a challenge. In this case, only 3/4 of the mesh was removed vaginally and was complicated by small bowel perforation due to adhesions. The remaining mesh was removed by careful dissection from the sacral base as the risk of infection in the mesh left behind is increased. Successful management eventually requires complete removal of the mesh at laparotomy. The surgery should be performed by experienced pelvic surgeons able to resolve intraoperative complications. Although serious complications are rare, patients should nonetheless be counselled about the risk of massive bleeding, bowel perforation, infection and rectovaginal fistula formation.     

Microwave endometrial ablation (MEA) and bowel injury

Microwave endometrial ablation (MEA) is regarded as an effective nonsurgical option for managing dysfunctional uterine bleeding (DUB). It is believed to be safe, quick, and easy to perform. To our knowledge, there has been only one reported case of a serious complication of a bowel injury during MEA. We report another similar case of accidental uterine perforation and bowel injury.This paper was accepted as an oral communication in the 13th Annual Congress of the European Society of Gynaecological Endoscopy at Cagliari, Sardinia, Italy, 14–18 October 2004.     

Migration of an intrauterine contraceptive device to the sigmoid colon: a case report.

BACKGROUND: Copper T intrauterine devices (IUDs) remain the mainstay of family planning measures in developing countries, but have been associated with serious complications such as bleeding, perforation and migration to adjacent organs or omentum. Although perforation of the uterus by an IUD is not uncommon, migration to the sigmoid colon is extremely rare. Here, we report a case of migration of an IUD to the sigmoid colon. CASE REPORT: A 40-year-old woman who had an IUD (Copper T), inserted 1 month after delivery, presented, 7 months later, with secondary amenorrhea and transient pelvic cramps. Clinical findings and ultrasonographic examinations of the patient revealed an 8-week pregnancy, while laboratory tests were normal. Transvaginal ultrasonography also visualized the IUD located outside the uterus, near the sigmoid colon, as if it were attached to the bowel. The pregnancy was terminated at the patient's wish; a diagnostic laparoscopy was performed concomitantly, which showed bowel perforation owing to the migration of the IUD. The device, which was partially embedded in the sigmoid colon, was removed via laparoscopy; however, because of bowel perforation, laparotomy was performed to open colostomy. CONCLUSIONS: This case report highlights the continuing need for intra- and postinsertion vigilance, since even recent advances in IUD technique and technology do not guarantee risk-free insertion.     

Angiographic control of pelvic bleeding from treated carcinoma of the cervix

Unremitting hemorrhage in two patients who had been treated by radiation for carcinoma of the cervix was managed by angiographic methods. In one patient, bleeding was shown to be from branches of the hypogastric artery and in the second, from branches of the inferior mesenteric artery. Selective embolization of the bleeding arterial branches with surgical gelatin (gelfoam) was followed by control of the acute hemorrhage in both patients.     

IUD removal with colonoscopy: a case report

BACKGROUND: Intrauterine device (IUD) perforation of the bowel is uncommon. Although IUD perforation may be asymptomatic, the most common complaint is unexplained abdominal pain. CASE: A case of IUD perforation of the large bowel was diagnosed 7 years after insertion. The patient presented with unexplained lower abdominal pain diagnosed initially as pelvic inflammatory disease. Laparoscopy revealed that the IUD was embedded deeply in the rectum. Bowel preparation and intravenous antibiotics followed by colonoscopy using a grasping snare resulted in successful IUD removal. CONCLUSION: Patients presenting with IUDs embedded in the large bowel may benefit from attempted removal using colonoscopy rather than laparotomy. Bowel preparation, intravenous antibiotics and pos-textraction evaluation to rule out perforation may be prudent.     

Atypical Ogilvie Syndrome

EDITORIAL COMMENT: Post-Caesarean section abdominal distension is a common problem, but spontaneous perforation of the colon, which occurred in this patient, is fortunately a very rare complication. The need for laparotomy in such patients is indicated by the clinical picture (e.g. sudden right hypochondrial pain and peritonitis as in this patient), not the findings on radiography. The Clinical Reports of the Mercy Maternity Hospital, 1971–1983, summarize the findings in the 173 patients who had laparotomy performed for surgical complications during pregnancy and the puerperium, during which time there were 56,842 confinements, including 6,938 Caesarean sections, in this hospital. There were cases of appendicitis (47), cholecystitis/cholelithiasis (12), carcinoma of the colon (I), bleeding Meckel diverticulum (1), volvulus of sigmoid (1), volvulus of small bowel (1), but there was not one case of intestinal perforation in this series.     

Clinical,pathologic, and genetic findings in a case of 46,XY pure gonadal dysgenesis (Swyer's syndrome): II. Presence of H-Y antigen

Evidence that expression of histocompatibility-Y (H-Y) antigen on human cells is determined by a Y-linked gene is provided by data demonstrating that male subjects with two Y chromosomes have higher antigen levels than male subjects with one Y chromosome. The widespread evolutionary conservation of H-Y antigen and its association with the Y chromosome suggest that the antigen has a specific, crucial function. We surmise that this function is the differentiation of the embryonic gonad into whichever mature gonad, testis or ovary, typifies the heterogametic sex of each species. Of particular interest are individuals whose gonadal sex does not correspond to their somatic genotype. In the present article, we report positive results in the first case of 46,XY pure gonadal dysgenesis (Swyer's syndrome) to be typed for H-Y antigen. This case suggests that the presence of H-Y antigen may not be sufficient to complete masculinization of the embryonic mammalian gonad. Alternatively, a mutant gene may govern expression of a cell surface component which cross reacts with H-Y antigen but which lacks the ability to function in the virilization of the gonad.     

Prenatal rectal perforation: an unsuspected cause of isolated ascites.

In fetal intestinal perforation, inflammation leads to production of ascites. Small bowel is usually involved by perforation with the distal ileum the most frequent site. We report the first case of prenatal perforation of the intraperitoneal part of the rectum, which presented as severe ascites at a 37 weeks' gestation antenatal ultrasonography. As none of the reported causes of intestinal perforation were identified in our case, its etiology remained idiopathic.     

Bowel perforation caused by an endoscopic stapler used during laparoscopically assisted vaginal hysterectomy. A case report

BACKGROUND: A commonly cited concern regarding laparoscopic hysterectomy is that the risks and complications associated with the procedure may be greater than those associated with more-traditional hysterectomy techniques. Among the potential risks that are unique to this approach are injuries caused by laparoscopic instrumentation. The events described below constitute the first known case of a postoperative bowel perforation caused indirectly by an automatic stapler used during a laparoscopically assisted vaginal hysterectomy (LAVH). CASE: A 52-year-old, African American woman underwent an uncomplicated LAVH, bilateral salpingo-oophorectomy and anterior repair in January 1995. Approximately nine months later, the patient began experiencing abdominal pain during a trip to Europe. Her condition progressively deteriorated to the point that an emergency landing in Iceland was required during her flight home. The patient was found to have a bowel obstruction and underwent a laparotomy and bowel resection. An open staple from the endoscopic stapler that was used at the time of LAVH was found to have caused the bowel perforation, which eventually resulted in adhesion formation and obstruction. CONCLUSION: Every effort should be made to remove loose staples from the operative field prior to termination of a laparoscopic procedure.     

Group A streptococcal toxic shock syndrome associated with pelvic peritonitis following diagnostic hysteroscopy in a healthy woman: a case report and review

We describe a case of group A streptococcal toxic shock syndrome (TSS) associated with pelvic peritonitis, occurring after a diagnostic hysteroscopy and curettage in a healthy woman. At laparotomy, performed to rule out bowel perforation, the diagnosis of pelvic inflammatory disease and pelvic peritonitis was confirmed. Her general condition deteriorated postoperatively needing supportive care in the intensive care unit, followed by gradual recovery. Although it is difficult to avoid a laparotomy in most cases following a surgical procedure, it is important to consider the diagnosis of streptococcal TSS associated with pelvic peritonitis from ascending sepsis in rapid onset, severely shocked cases.     

Small bowel perforation without tumor recurrence after radiotherapy for cervical carcinoma: report of seven cases

AIM: We describe the clinical presentation, evaluation, management and outcome of patients experiencing small bowel perforation following radiation therapy for cervical cancer. METHODS AND MATERIALS: A database consisting of 95 Japanese women with stage 0-4 A cervix cancer treated between 1991 and 2004 contained seven patients (7.4%) with small bowel perforation. RESULTS: The median age at the time of perforation was 72.5 years (range 62-78). The median time from completion of radiotherapy to perforation was 6 months (range 2-58). Surgery (one small bowel resection and anastomosis with diversion; six small bowel resection and anastomosis) was performed immediately in all seven patients. One of seven patients died of small bowel perforation (i.e. mortality rate was 14%). Bowel adhesion was detected during the operation in only three cases (43%). Signs of peritonitis were absent in six cases (86%). Severe abdominal pain was seen in all seven patients. The perforation site was ileum in all seven cases. In all patients, pathological changes were compatible with postirradiation injury of the gastrointestinal tract. CONCLUSIONS: The presenting complaints of patients with bowel perforation following radiotherapy vary, and signs of peritonitis may be absent. Emergency physicians must be alert for these complications in patients who have been treated with radiotherapy.     

Spontaneous perforation of the cecum after cesarean section

The literature concerning perforation and imminent perforation of the caecum after cesarean section is reviewed. One case has been observed by the author. Increasing caecal diameter above 10 cm gives rise to suspicion of an imminent perforation of the caecum. Medical treatment and colonoscopy may be tried. In case of unresponsiveness or if occurrence of a cecal perforation, surgical intervention (cecostomy) is indicated.     

Major surgical complications of laparoscopy

During the 15-yr period from 1965 to 1979, 6 major surgical complications were encountered among 2757 consecutive laparoscopies, yielding a rate of 2.1 per 1000. Five of the complications required exploratory laparotomy (in 2 patients with small bowel perforations, 2 patients with intraabdominal bleeding and 1 patient with severe peritonitis). In the 6th patient perforation of the uterine fundus occurred during laparoscopy performed because the presence of an adnexal mass was suspected at 15 wk gestation. Laparotomy in this patient was not performed since bleeding from the perforation site stopped spontaneously. Exploratory laparotomy rather than laparoscopy should be considered for evaluation of pelvic masses suspected after the first trimester of pregnancy. A small rate of major surgical complications of laparoscopy is to be expected even when accurate technique is used.     

Prenatal ultrasonic diagnosis of multiple bowel atresias

This case illustrates the course of an obstructive process through spontaneous perforation resulting in decompression of dilated bowel loops. The resulting meconium peritonitis appeared as fetal ascites. Postnatal investigations and laparotomy confirmed the diagnosis of a rare form of multiple congenital atresias of the bowel.     

Intestinal perforation during pregnancy

Three cases of bowel perforation were encountered in pregnant women in a community hospital. Two were associated with mechanical obstruction, and one was of unknown etiology. Displacement of abdominal contents by the gravid uterus may predispose pregnant patients to intestinal obstruction in the presence of an underlying bowel abnormality, such as adhesions or malrotation. Prompt diagnosis and appropriate therapy are necessary to avoid a fatal or a severely morbid outcome.     

带蒂腹直肌肌瓣用于盆腔廓清术盆底重建的初步探讨

Objective?To explore the feasibility and short-term effectiveness of pelvic floor reconstruction by pedicle rectus abdominis muscular flap after pelvic exenteration. Methods?Eight patients with pelvic floor reconstruction by pedicle rectus abdominis muscular flap after pelvic exenteration between October 2019 and June 2021 were reviewed and analysed retrospectively. Results?The patients were from 39 to 68 years old(median age 57.5), 2 pelvic floor reconstructions with partial pedicle rectus abdominis muscular flap, 6 pelvic floor reconstructions with whole pedicle rectus abdominis muscular flap, the reconstruction time were 60 to 90 minutes. 1 case had ureteral fistula and underwent further surgical repair. 2 cases complained of increased vaginal discharge, they were all improved with anti infection therapy after 1 month and without any further surgical intervention. Abdominal incision infection occurred in 2 cases, and the wound healed after debridement. The patients were followed up 2 to 13 months (median 6.5 months), 1 case died of tumor recurrece 4 months after surgery, and 7 patients survived. There was no late complication, such as bowel obstruction, bowel perforation and fistulas. There was no early and late muscular flap related complications. Conclusion?The pedicled rectus abdominis muscular flap is a safe, effective, simple and rapid method for pelvic floor reconstruction after pelvic exenteration.