Generalised purulent peritonitis and small bowel obstruction due to a spontaneously perforated ovarian dermoid cyst

Abstract

We outline the narrative of a 28-year-old woman who initially presented to the emergency department with vomiting, diarrhoea, abdominal pain and fever. Blood tests revealed significantly raised inflammatory markers and acute renal failure. Initially, this was attributed to gastroenteritis due to a recent foreign travel, but further investigations and radiological imaging revealed a large right ovarian dermoid cyst with a significant amount of free intra-abdominal fluid and small bowel dilation. She underwent laparotomy, which revealed a spontaneously perforated right ovarian dermoid cyst resulting in generalised purulent peritonitis and small bowel obstruction due to bowel adherence at the perforation site. Meticulous adhesiolysis, right salpingo-oophorectomy and extensive peritoneal lavage were performed, with a good postoperative recovery. Spontaneous perforation of an ovarian dermoid cyst, without an associated torsion, is extremely rare, but it should be considered in cases of peritonitis and bowel obstruction of unclear cause with a concomitant finding of a dermoid cyst.

Clinical characteristics and laparoscopic surgical outcomes of ovarian dermoid cysts complicated by spontaneous rupture: nine cases and a literature review

“…Patients with acute disease present with severe acute abdominal symptoms, such as pain, 5 while chronic chemical peritonitis has an insidious symptom onset. [5][6][7]11 Worsening peritoneal damage caused by leaked sebaceous materials may be accompanied by other complications, such as pelvic adhesive disorder or bowel obstruction, abdominal wall abscesses, enterocutaneous fistula formation. 5 Abdominal symptoms therefore develop eventually, even under chronic conditions, including progressive abdominal pain, abdominal distention, fever, and gastrointestinal disturbances such an anorexia, nausea, vomiting, and diarrhea.…”

“…Once rupture of the dermoid cyst is diagnosed or highly suspected, immediate surgical intervention is needed to remove the ovarian cyst, along with thorough peritoneal lavage, 5–8,11,14 although conservative non-surgical management can be considered on extremely rare occasions. 15 Laparoscopic surgery is an accepted feasible option for the surgical management of dermoid cysts.…”

“…Dermoid cysts can rupture accidentally during surgery 10 or spontaneously [5][6][7]11 ; however, spontaneous rupture is rare (reported prevalence: 0.3%-2%) because of their usually thick capsular wall. 11 A similar incidence of rupture (0.8%) was observed in the current case series.…”

“…In the worst-case scenario, rupture of dermoid cysts into the peritoneal cavity, resulting in leakage or spillage of the cyst contents with sebaceous material, may induce chemical peritonitis, which is an aseptic inflammatory peritoneal reaction. [5][6][7]11 The clinical symptoms of chemical peritonitis caused by dermoid cyst rupture may be acute or chronic, depending on the duration and amount of leakage. 5 Acute chemical peritonitis is induced by massive leakage of sebaceous material due to a sudden extensive cyst rupture, while slow leakage through a small tear in the wall of the dermoid cyst may cause chronic granulomatous peritonitis.…”

“…4,5 Furthermore, chemical peritonitis caused by leakage of sebaceous material into the peritoneal cavity can cause significant comorbidity before and even after surgery. [5][6][7] However, the clinical characteristics, imaging findings, and preoperative blood indices and serum tumor markers that can help to differentiate between spontaneous rupture and torsion are not well documented.…”