A rare case of acute abdomen: spontaneous rupture of degenerated fibroid
- Nidhi Goswami and
- Aderemi Alalade
- Obstetrics and Gynaecology, Wrexham Maelor Hospital, Wrexham, UK
- Correspondence to Dr Nidhi Goswami; nidhi.goswami@outlook.com
Abstract
A 29-year-old nulliparous woman presented with an acute abdomen. She had a large uterus with multiple fibroids and was on the waiting list for elective surgery. An urgent CT scan demonstrated an extensive intraperitoneal fluid collection suspicious for fibroid rupture. She required an emergency laparotomy which identified a rupture of the largest degenerative fibroid. There was 2 Litres of pus in the peritoneal cavity. This case was a rare presentation of spontaneous fibroid rupture due to degeneration and necrosis, and acute abdomen from peritoneal irritation. Imaging was vital in making the diagnosis, and urgent surgical intervention was essential to reduce morbidity and mortality.
Background
Uterine myomas are the most common solid pelvic tumours in women.1 By the age of 50, the estimated cumulative incidence of the tumour is over 80% for black women and nearly 70% for caucasian women.2 They are clinically apparent in up to 25% of women and cause significant morbidity, including prolonged or heavy menstrual bleeding, pelvic pressure, pain and in rare cases reproductive dysfunction.3 However, uterine myomas rarely present with acute complications like thromboembolism, acute pain (due to degeneration or torsion of a pedunculated fibroid) or acute intra-abdominal blood loss.4 They rarely require emergency surgical intervention.
Case presentation
A 29-year-old nulliparous woman presented to the accident and emergency department with acute abdominal pain. She also reported nausea, vomiting, upper abdominal pain on deep inspiration and shortness of breath. There was no history of vaginal bleeding, vaginal discharge or associated bowel and bladder symptoms. Her previous MRI revealed multiple uterine fibroids (two large subserosal fibroids 13 cm and 11 cm; and a 6 cm intramural fibroid). The larger of the two subserosal fibroids (13 cm) was located at the uterine fundus, and the other was located slightly inferior to this (adjacent to the left cornua of the uterus). She was on the waiting list for an elective myomectomy (figure 1A,B).
(A, B) Pre-rupture MRI images (sagittal and cross-section) demonstrating multiple large subserosal and intramural fibroids.
On examination, the patient was conscious and oriented. She was afebrile (temperature 35.8°C), and her blood pressure was stable at 124/80 mm Hg. However, she was tachycardic with a heart rate of 113 beats/min and tachypnoeic with a respiratory rate of 20 breaths/min. She required intranasal oxygen to maintain her saturation levels. Examination of the chest showed shallow breathing with reduced air entry in the lower lung zones bilaterally. Abdominal examination revealed a distended abdomen with a firm uterine mass of about 40-weeks size. There was diffuse tenderness, guarding and rebound tenderness.
Investigations
The patient’s full blood count revealed raised inflammatory markers (white cell count 26.0×109/L) and normal haemoglobin of 129 g/L. She had a negative urine pregnancy test. An urgent CT scan reported degenerative changes in the largest fibroid with massive fluid collection in the peritoneal cavity (figure 2A,B).
(A, B) CT scan images demonstrating degenerative changes detected within the largest fibroid (white arrowhead) with a massive intraperitoneal fluid collection.
Differential diagnosis
The working clinical diagnosis was that of a ruptured fibroid with an intraperitoneal fluid collection. However, differential diagnoses considered include fibroid torsion, intra-abdominal/pelvic infection and non-gynaecological causes of an acute abdomen (including bowel perforation, appendicitis and cholecystitis).
Treatment
The patient consented to an emergency exploratory laparotomy, myomectomy with the possibility of a hysterectomy and bowel surgery. Operative findings confirmed a rupture of the largest fibroid with degenerative changes (figure 3). There was approximately 2 L of blood-stained purulent fluid within the abdomen, with inflammatory exudates covering the pelvic organs, bowel and upper abdomen. The collection was drained to aid visibility of the abdominal and pelvic organs. The omentum, bowels and pelvic organs were carefully separated and mobilised. The uterus was reconstructed in the standard fashion after removing all the fibroids. The ovaries and fallopian tubes appeared normal. Peritoneal lavage was performed, and a non-suction surgical drain (size 24 Robinson) was inserted in the peritoneal cavity. The total blood loss was 500 mL. She required one unit of blood transfusion and was given intravenous antibiotics for 48 hours following surgery.
Degenerative fibroid rupture site.
Outcome and follow-up
The patient’s postoperative course was complicated by bacterial pneumonia which was managed with antibiotics, and she was discharged home in a stable condition on the seventh day after surgery. She was seen at an outpatient clinic 6 weeks after discharge from the hospital. She had resumed routine day-to-day activities and recovered well from her operation. The histology report revealed extensive necrosis with mixed inflammatory cell infiltrate and hyalinisation at the periphery. There were areas of extensive infarction with no evidence of atypia or malignancy. The other fibroids excised revealed simple leiomyomata.
Discussion
Fibroids are ovarian-steroid hormone dependent tumours. They are common in the reproductive years, and their growth is dependent on the levels of circulating oestrogen and progesterone.1 5 The majority of women with fibroids present with prolonged heavy menstrual bleeding or pressure-related symptoms which are typically on surrounding organs, such as bladder and bowel, resulting in difficulty passing urine or defaecation. They seldomly present with acute abdominal pain related to torsion of a pedicle, infection or sarcomatous changes within the fibroid.1
Degeneration of fibroid can result from excessive growth, which causes the fibroid to exceed its blood supply, or from mechanical compression of feeder vessels. Hyaline degeneration is the most common change accounting for about 63% of cases. Cystic degeneration tends to occur following hyaline degeneration in a few cases.6 Fibroid cases presenting with haemoperitoneum are relatively uncommon. Many case reports describe haemoperitoneum arising from a bleeding vessel on the surface of the fibroid.7–12 These have been attributed to venous congestion, overstretching of the capsule and subsequent rupture of superficial veins and seem to occur mainly in fibroids greater than 10 cm.8–10 Some authors have described activities that could promote pelvic venous congestion or increase intra-abdominal pressure (such as strenuous physical exercises, weight-bearing and defaecation) as the precipitating factors to vessel rupture in patients with fibroids.9 11 Vessel rupture reported in an obstetric patient has been attributed to degenerative changes associated with pregnancy and the shearing forces exerted on the capsule by uterine contractions during labour.7
Imaging studies are vital in managing patients with acute abdomen due to the limitations of clinical evaluation. Ultrasound is adequate in most cases and is considered the primary imaging-method of choice with the added benefit of no radiation exposure. However, it has low sensitivity for minimal changes, is highly user-dependent and is limited by skill availability when patients present out of hours. Studies have shown that a CT scan is the most sensitive imaging investigation for detecting urgent conditions in patients with abdominal pain, and will be useful in cases with inconclusive ultrasonography results.13
In this case, an exploratory laparotomy was considered the best management option as it also provided an opportunity to exclude or manage other potentially life-threatening differential diagnoses. Other modalities of fibroid management, such as uterine artery embolisation, were not suitable in this case due to the clinical findings of an acute abdomen.14
This case describes a relatively uncommon presentation. There are fewer than 10 acute abdomen cases due to rupture of a degenerated fibroid in the literature. The reported cases were associated with trauma, miscarriage, perimenopause and the puerperium.15–17 Our case occurred spontaneously without any of these risk factors. The theory associating haemoperitoneum to superficial vessel rupture, as described above, would not explain the findings during laparotomy in this case. There was no bleeding vessel on the capsule of the fibroid at the surgery. Schwartz et al, in their report, suggested that degenerative changes within a fibroid could lead to necrosis and subsequent perforation of the capsule, causing bleeding into the peritoneal cavity.18 This theory would explain the pus seen at laparotomy in this case. The infected cystic degeneration within the fibroid could have led to necrosis, followed by capsular distention, perforation and leakage of its content into the peritoneal cavity. Tan and Aruku’s article suggested that infection could lead to the formation of a pyomyoma which was confirmed on the histology specimen in this case.17 Notably, the patient described an acute onset of pain which started about 24–48 hours before presentation at the emergency department. This pain was different from her usual background discomfort due to large fibroids. This acute pain likely coincided with the breach of the fibroid capsule and the onset of the leakage of infected degenerated contents into the peritoneal cavity.
Learning points
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Rupture of a uterine fibroid is rare but is a potential surgical emergency.
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A high index of suspicion is required for fibroid related acute events.
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Use of imaging can be very useful in making a diagnosis.
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Timely diagnosis and urgent intervention are required to reduce morbidity and mortality.
Footnotes
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Contributors NG instigated, researched and wrote the article. AA did further research and edited the article. Both NG and AA read and approved the final version of the manuscript and agree with its submission to BMJ.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
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Patient consent for publication Obtained.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.
References
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