Small bowel obstruction and perforation attributed to tubo-ovarian abscess following 'D’ and 'C’
© Weledji and Elong; licensee BioMed Central Ltd. 2013
Received: 21 July 2013
Accepted: 6 October 2013
Published: 9 October 2013
We report the case of a young woman who was admitted because of small bowel obstruction and localized peritonitis following a dilatation and curettage ('D’ and 'C’) of uterus in abortion. As infection, like tubo-ovarian abscess may complicate any abortion, it seems wise to ensure that it does not exist prior to performing a 'D’ and 'C’.
KeywordsDilatation and curettage Pelvic abscess Intestinal obstruction Perforation
Small bowel obstruction is a serious and costly medical condition indicating often emergency surgery. Currently small bowel obstruction required 948,000 hospital days annually, amounting for $3.2 billion, with a rate of 117 hospitalizations per 100,000 people. It constitutes 1.9% of all hospital and 3.5% of all emergency admissions that has led to laparotomy in the United States . Tubo-ovarian abscess is often thought to arise from repeated episodes of pelvic inflammatory disease (PID) but may also arise after perforations of septic or even therapeutic abortions; after adnexial surgery or caeserian section; from a ruptured appendix; with pelvic malignancy, or rarely after apparently uncomplicated minor gynaecological procedures including removal or insertion of intra-uterine devices and deliveries [2–4]. Small bowel obstruction attributed to tubo-ovarian abscesses have been reported but without a link to a precipitating factor such as in this case- the 'D’ and 'C’ procedure [5–7].
A 22-yr old woman (G2 P1011) was admitted as an emergency with a gradual onset severe colicky central abdominal pain 1 week after a termination of pregnancy at 16 weeks gestation. The pain became more frequent on a background of a constant lower abdominal pain. There was associated central abdominal distension, copious bilious vomiting following meals, absolute constipation and fever. There was no vaginal discharge. She had undergone a normal vaginal delivery 15 months previously. On examination she was in great distress, lying still but restless with each episode of colic. She was dehydrated and tachypnoeic. Her blood pressure 100/60 mmHg, heart rate 90/min and temperature 39°C. She had a distended abdomen with visible peristalsis and generalized rebound tenderness. Adnexal structures were unable to be palpated. The clinical impression was small bowel obstruction secondary to peritonitis from a perforated uterus as a complication of the 'D’ and 'C’. Her haemoglobin level was 12.2 gms/d but a white cell count was not available. An abdominal ultrasound scan from the referral clinic revealed a non-gravid uterus with dilated loops of bowel and free intraperitoneal fluid. Following resuscitation with intravenous fluids, nasogastric suction, intravenous antibiotics and analgesia she underwent a laparotomy.
Laparotomy revealed copious (~ 1-2l) amount of clear, 'transudate’ fluid in the peritoneal cavity associated with a markedly distended small bowel. There was a localized area of terminal ileal stricture at the site of adhesion of a right tubo-ovarian abscess of about 6 cm in diameter. Immediately proximal to the stricture was dilated small bowel with serosal tears suggesting impending perforation. There was a short segment of a distally collapsed terminal ileum. On mobilisation, a large amount of pus drained from the tubo-ovarian mass into the terminal ileum i.e. an internal tubo-ovarian small bowel fistula. Apart from an inflammatory exudate surrounding the uterus there was no perforation. The left adnexa was normal. A retroileal appendix adherent to the infundibulo-pelvic ligament appeared normal. The distended bowel was decompressed by suction via the terminal ileal perforation. The strictured segment of small bowel including the perforation was resected. A salpingo–oophorectomy and an appendicectomy were done. A manual end-to-end ileal anastomosis was fashioned and the abdominal cavity thoroughly lavaged with copious amount of saline. No drain was inserted because of the friable nature of the bowel and the localized nature of the peritonitis. Unfortunately, due to financial difficulties, microbiology of the purulent exudate was not requested and the excised specimen was not sent for histological examination. She received a therapeutic course of intravenous ceftriaxone 1 gm tds and metronidazole 500 mg tds for 7 days that covered the aerobes and anaerobes for a week. Apart for an ileus of 3 days, her recovery was uneventful. She was discharged on the 9th postoperative day on a 1 week course of doxycycline against Chlamydia trachomatis a frequent cause of pelvic inflammatory disease.
Published articles on bowel obstruction due to tubo-ovarian abscess
Authors and year of publication
Weledji et al., 2013
Pines et al., 2008
Harel et al., 2003
This case highlights the importance of requesting an ultrasound scan of the pelvis prior to performing a dilatation and curettage for abortion. This would not only confirm an intrauterine pregnancy but may also reveal an ectopic pregnancy, a co-existing tubo-ovarian abscess or other adnexal pathology.
“Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal” 13. 07; 41473.
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