POLSKI PRZEGLĄD CHIRURGICZNY 2014, 86, 7, 341–344

10.2478/pjs-2014-0060

Autoamputated leiomyoma of the uterus as a rare cause of the mechanical bowel obstruction – report of a case Mateusz Rubinkiewicz1, Jakub Kenig2, Katarzyna Zbierska3, Anna Lasek3 2nd Department of Surgery1 Kierownik: prof. dr hab. K. Rembiasz 3rd Department of General Surgery2 Kierownik: prof. dr hab. W. Nowak Faculty of Medicine3 Jagiellonian University Collegium Medicum in Cracow Mechanical obstruction of the gastrointestinal tract is one of the most common causes of the emergency surgical intervention. A rare cause of such condition might be the effect of the external pressure on the intestine exerted by i. e. tumor, lymph node package, aneurysm of the abdominal aorta. An extremely rare cause is the pressure of the large loose mass located in the peritoneal cavity called “loose body”. We present a case of the mechanical bowel obstruction caused by a giant loose autoamputated leiomyoma of the uterus lying free in the peritoneal cavity. According to our best knowledge it is the largest described loose body in the literature. Moreover, we present a literature review regarding this issue. Key words: peritoneal loose body, leiomyoma, mechanical obstruction

Diagnostics of the acute abdominal conditions remain a big challenge for clinicians despite the enormous development in the field of medicine. One of the most common emergency intervention concerning abdomen comprises intestinal obstruction. There are many causes that may lead to this condition, such as neoplasm, volvulus, strangulated hernia. An obstruction may also be an effect of the external pressure on the intestine exerted by i. e. tumor, adhesions (1) or in rare cases by free abdominal bodies. Case report We present a case of 70-year-old patient with the mechanical bowel obstruction caused by a big loose autoamputated leiomyoma of the uterus presenting in the peritoneal cavity. At the time of admission her general condition was severe, she was on the verge of the cardio-

vascular and respiratory insufficiency. She presented with a two weeks history of the aggravating symptoms of bowel obstruction without any medical consult. The patient had two myocardial infarctions and long-term rheumatoid arthritis in the past medical history. On examination, abdominal distension with muscle guarding and rebound tenderness. The abdominal X-ray revealed fluid levels in the intestines and free intra-abdominal air under the diaphragm. In the ultrasound of the abdomen free fluid in the perisplenic space and between intestinal loops as well as multiple myomas in the uterus were detected. Performed laboratory tests revealed increased CRP level (311 mg/L) with WBC within normal range (8.2 thousands/µl). After the necessary preparation the patient was qualified to exploratory laparotomy. The peritoneal cavity was opened with median incision extending from the xiphoid cartilage to ten centimetres below the umbilicus. Ap-

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proximately 3 litters of purulent fluid was sucked off and swab samples for microbiological environmental testing were collected. Control of abdominal cavity organs revealed perforation in the prepyloric part of the stomach, 2 cm in the diameter, as well as the automaputated tumor with dimensions 20 x 10 cm in the vicinity of the uterus, exerting pressure on the sigmoid colon and causing mechanical obstruction. A partial rupture of transverse colon and symptoms of critical ischemia of the cecum were also detected. Due to the above-mentioned discoveries a total colectomy with end ileostomy was performed. Subsequently, gastric wedge resection with ulceration removal was performed. The stomach wall was sutured using Heineke-Mikulicz method. The specimen from the procedure was sent for histopatological examination. Due to the severe general condition the patient was postoperatively transferred to the Intensive Care Unit for the further treatment. The tumor causing the obstruction proved to be an autoamputated leiomyoma of the uterus (fig. 1, 2). The patient’s general condition was constantly deteriorating and eventually the patient died presentig the symptoms of multiorgan disfunction syndrome.

Free bodies in the peritoneal cavity were first mentioned by Littere and Virchov at the turn of the 19th century (2). Precise definitions emerged though in the middle of 20th century and free body in the peritoneal cavity was

defined as white object with lamellar structure and yellow core in the cross-section (3). Ultrastructurally, its core comprise necrotic remains of adipose tissue and peripheral parts consist of calcificated tissue (2). Small free bodies, less than 2 cm in diameter, are very common accidental findings during laparotomy performed due to the other indications, in radiological examinations or during autopsy. The most of free bodies is considered to form as an effect of necrotic and calcification processes of epiploic appendices, that separated from the colon due to the twisting of their peduncules or local ischemia (4, 5). Similar structures may also create in cases of detached lipomas or pedunculated leiomyomas of the uterus, that underwent necrosis due to the torsion or surgical intervention such as leiomyoma embolization. In the literature there is a case report, in which a free body comprised adnexa of uterus, that have twisted in the patient’s childhood and were accidentally discovered thirty years later as a typical calicificated free body (6). Small free bodies usually remain asymptomatic and do not demand any surgical intervention (4, 7). Whereas big free bodies more than 5 cm in diameter are a very rare finding but they may be symptomatic. The largest loose bodies described in the literature are presented in Table 1. Most commonly they are situated in rectovesical pouch in men and rectouterine pouch in women, which is explained by law of gravity (2). Generally, they remain asymptomatic for a long time, they may though cause discomfort in the abdomen, chronic pain and even obstruction if a free body exerts external pressure on

Fig. 1. The leiomyoma extracted from the peritoneal cavity during the surgery

Fig. 2. Longitudinal cross-section of the leiomyoma

Discussion

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Autoamputated leiomyoma of the uterus as a rare cause of the mechanical bowel obstruction

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Table 1. The largest peritoneal loose bodies reported in the literature. Authors

Year

Type of tumour

Burns JB, Rogers JV Jr. Bhandarwar AH et al. Takada A et al. Shuto T et al. Nomura H et al. Asabe K et al. Ghosh et al. Takabe K, Greenberg JI, Blair SL. Mohri T et al. Takayama S, Sakamoto M, Takeyama H. Koga K et al. Hedawoo JB, Wagh A Sewkani A et al. Gayer G, Petrovitch I Jang JT et al. Nozu T, Okumura T

1969 1996 1998 2002 2003 2005 2006 2006 2007 2009 2010 2010 2011 2011 2012 2012

sequestered ovary peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body amputated adnexa peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body peritoneal loose body

the intestine (2, 8), such as in the case reported in this paperwork. Then a typical bowel obstruction develops. Similar situation occurs when the pressure is exerted on ureter and it causes urine retention in the renal pelvis leading to hydronephrosis (9). In case of asymptomatic free bodies it is crucial to differentiate them from neoplasms originating from gastrointestinal tract, female reproductive system or urinary system (7). Distinctive feature of free bodies in the computed tomography is lack of enhancement after the contrast application. In magnetic resonance imaging a free body is a hypointense lesion in T1 and T2 sequences (4, 10). It may be helpful for differentiation between free body and neoplasm to observe changes in its location depending on patient’s body position (5, 11). Important is to remember that the migration of such object may be substantially impeded by the adhesions or abdominal organs in the vicinity. The calcification is a slow process and consecutive layers may also consist of exfoliated epithelial cells originating from the organs in the peritoneal cavity, as well as peritoneal fluid bonded on the surface of free body (10). According to our best knowledge, as far there is only one reported case of free body detected during routine examination and being under observation for several years. The patient did not gave consent for surgical removal of the object, which stayed asymptomatic for few

Number of tumours 1 1 2 1 1 1 2 2 1 1 1 1 1 1 1 1

Size (in milimeters) 70x80 60 x70 both 18 in diameter 50x40 30 in diameter 58x45, 52x45 42x33, 32x22 95x75 45x40 30x20 95x86 70x50 30 in diameter 45x40 40 in diameter

years. Eventually, the patient returned to the same hospital due to the aggravating abdominal pain in the left lower quadrant. Computed tomography revealed enlargement of free body from 7,3x7 cm to 9,5x7,5 cm. Laparotomy was performed and the object was removed (4). In the case of our patient more sophisticated imaging examinations were not performed due to the symptoms of diffuse peritonitis and the necessity of urgent surgical intervention. Intraoperatively, typical mechanical obstruction caused by an external pressure was observed. Removed myoma did not have a classic appearance of free body, namely whitish calcificated peripheral parts and yellowish core often compared to a boiled egg. The tumor had cohesive consistency and was covered with fibrin. Probably, its isolation from the uterine wall happened not long before the onset of symptoms, which hindered the processes of necrosis, calcification and saponification. According to our best knowledge, the above-described case is the largest free body found in the peritoneal cavity as far. Its dimensions (20x10 cm) considerably exceed the size of hitherto reported cases (so far the biggest had approx. 9x9 cm) (4, 5). However, the process of transformation of the detached fragment of tissue causing a formation of free body is not entirely known. Therefore, it is hard to determine its final size after all these alterations.

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The concern about detached myomas needs to be particularly emphasized with the regard to the increasing popularity of uterine myomas embolisation procedure. A common consequence is so-called postembolization syndrome, which is a result of local ischemia of the tissues (12). Its manifestation comprises fever and local pain of the operation site. Usually the symptoms subside spontaneously after 2-3 days (13, 14). It is though possible that in some specific cases a large myoma may detach from the uterus following the ischemia of its peduncle. Such situation may lead to the clinical manifestation described in our patient’s case.

Conclusions Free body in the peritoneal cavity, especially large ones, are rarely a substantial clinical problem and they remain asymptomatic. Surgical removal of such object is recommended only if they are symptomatic or when it is not possible to differentiate the finding from a neoplasm. In the justified cases of presumable free body in the peritoneal cavity the laparoscopic approach is suggested. It is crucial to remember that such a big structure may cause a mechanical obstruction and it should be taken into consideration in such conditions.

references 1. F. Brunicardi, Dana Andersen, Timothy Billiar et al.: Schwartz’s Manual of Surgery, 8th ed., The McGraw-Hill Companies; 2006. 2. Ghosh P, Strong C, Naugler W et al.: Peritoneal Mice Implicated in Intestinal Obstruction Report of a  Case and Review of the Literature. J Clin Gastroenterol 2006; 40: 427-30. 3. Southowood WF: Loose body in the peritoneal cavity. Lancet 1956; 271(6952): 1079. 4. Jang JT, Kang HJ, Yoon JY et al.: Giant Peritoneal Loose Body in the Pelvic Cavity. J Korean Soc Coloproctol 2012; 28(2): 108-10. 5. Gayer G, Petrovitch I: Diagnosis of a large peritoneal loose body: a  case report and review of the literature. Br J Radiol 2011; 84(1000): e8385. 6. Koga K, Hiroi H, Osuga Y et al.: Autoamputated adnexa presents as peritoneal loose body. Fertil Steril 2010; 93(3): 967-68. 7. Shuto T, Hirohashi K, Kubo S et al.: A Case of a Peritoneal Loose Body that was Embedded in the Liver and Undistinguishable from a  Metastatic Tumor. Osaka City Med J 2002; 48: 119-21.

8. Sewkani A, Jain A, Maudar K et al.: ’Boiled egg’ in the peritoneal cavity-a  giant peritoneal loose body in a  64-year-old man: a  case report. J Med Case Rep 2011; 7(5): 297. 9. Bhandarwar AH, Desai VV, Gajbhiye RN et al.: Acute retention of urine due to a loose peritoneal body. Br J Urol 1996; 78(6): 951-52. 10. Takada A, Moriya Y, Muramatsu Y et al.: A Case of Giant Peritoneal Loose Bodies Mimicking Calcified Leiomyoma Originating from the Rectum. Jpn J Clin Oncol 1998; 28(7): 441-42. 11. Nozu T, Okumura T: Peritoneal Loose Body. Intern Med 2012; 51(15): 2057. 12. Gupta JK, Sinha AS, Lumsden MA, et al.: Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev 2006; 25(1): CD005073. 13. Walker WJ, Pelage JP, Sutton C: Fibroid embolization. Clin Radiol 2002; 57(5): 325-31. 14. Prollius A, de Vries C, Loggenberg E et al.: Uterine artery embolisation for symptomatic fibroids: the effect of the large uterus on outcome. BJOG 2004; 111(3): 239-42.

Received: 18.11.2013 r. Adress correspondence: 31-530 Kraków, ul. św. Łazarza 16 e-mail: m.rubiniewicz@com.

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Autoamputated leiomyoma of the uterus as a rare cause of the mechanical bowel obstruction - report of a case.

Mechanical obstruction of the gastrointestinal tract is one of the most common causes of the emergency surgical intervention. A rare cause of such con...
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