Differentials
Irritable bowel syndrome (IBS)
SIGNS / SYMPTOMS
It may be difficult to distinguish ovarian cancer from IBS.
Physical examination revealing a pelvic mass should cause suspicion for a non-gastrointestinal process.
INVESTIGATIONS
As there is no disease biomarker for IBS, diagnosis is made with the Rome IV criteria, defined as recurrent abdominal pain on average at least 1 day per week in the last 3 months and associated with ≥2 of the following criteria: related to defecation; associated with a change in frequency of stool; and associated with a change in form (appearance) of stool.[100]
Metastases to the ovary
SIGNS / SYMPTOMS
In one study, metastases to the ovary accounted for 15% of all ovarian malignancies.[101] The most common primary site was the gastrointestinal tract (Krukenberg tumours) (39%).[101]
Breast and endometrial cancer can also metastasise to the ovary.[101] In general, metastasis to the ovaries tends to be solid and is not associated with ascites.[102]
INVESTIGATIONS
Imaging may not differentiate between primary organ sites.
Colonoscopy and/or upper endoscopy may be used to diagnose cancer originating in the gastrointestinal tract.
Additional tumour markers (CEA, CA 19-9, CA 27-29) should be considered as clinically indicated.
Histopathology is usually the distinguishing test.
Endometriosis
SIGNS / SYMPTOMS
Endometriosis mainly occurs in pre-menopausal women, as opposed to ovarian cancer, which mainly occurs in older patients.
Pelvic pain is a common symptom for both ovarian cancer and endometriosis, and thus is not helpful in distinguishing the two conditions.
Approximately 50% of clear cell ovarian carcinomas are associated with endometriosis.[103] The exact nature of this relationship is unclear.[2]
INVESTIGATIONS
Histopathology is usually the distinguishing test.
Diverticular disease
SIGNS / SYMPTOMS
May be asymptomatic, and the process is noted as an incidental finding on colonoscopy or barium enema.
An acute episode of diverticulitis can be associated with fever, leukocytosis, and left lower quadrant pain.[104]
INVESTIGATIONS
Barium enema or colonoscopy can be used to diagnose diverticular disease.
When active inflammation is present, a CT scan can demonstrate inflammation (seen as stranding) in the sigmoid colon.
Meigs syndrome
SIGNS / SYMPTOMS
Mainly seen in older women, the triad of ascites, hydrothorax, and a benign ovarian tumour comprises Meigs syndrome.
Signs and symptoms include tachypnoea, tachycardia, and decreased breath sounds usually on the right side.
INVESTIGATIONS
Investigations may reveal a benign pelvic mass, electrolyte abnormalities, prolonged prothrombin time, and sometimes elevated CA-125.
Chest x-ray confirms pleural effusion, with ultrasound or CT showing a mass without metastasis.
Thoracentesis and paracentesis are negative for malignant cells.
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