Gynecologic Pathology as it Relates to General Surgery

Lily Shamsnia, MDDepartment of Obstetrics and Gynecology

Tulane University School of Medicine

GYN vs. General Surgery

• Many Gynecologic disorders mimic those of General Surgery, especially regarding etiology of acute and chronic pelvic pain, as well as the diagnosis/treatment of an acute abdomen.

• Abdominal pain may be infectious, inflammatory, anatomic or neoplastic

Acute right lower abdominal pain in women of reproductive age: Clinical clues Hatipoglu, et. al

Patient (n=290), n (%) Age (yr)

Acute appendicitis 224 (77.2) 21 (12-24)

Perforated appendicitis 29 (10) 22 (14-42)

Ovarian cyst rupture 21 (7.2) 24 (15-38)

Corpus hemorrhagic cyst rupture 12 (4.2) 21 (13-55)

Adnexal Torsion 4 (1.4) 24 (19-30)

290 female patients presenting to ED with acute abdominal pain

Alvarado ScoreAlvarado Score Point Value

Abdominal pain migrating to RLQ 1

Anorexia or urine ketone 1

Nausea or vomiting 1

Tenderness in RLQ 2

Rebound tenderness 1

Fever 1

Leukocytosis 2

Neutrophilia 1

Scoring: 0-4: unlikely appendicitis 5-6: consistent with dx of appendicitis 7-8: probable appendicitis 9-10: very probable appendicitis

Symptoms/signs of appendicitis similar to many GYN disorders

Approach to Acute Abdominal/Pelvic pain in a Female

• History and physical exam• Bimanual and speculum exam• UPT/ serum bHCG• Cervical cultures • Radiologic studies

DDx pelvic pain of GYN origin

• Pelvic Inflammatory Disease (PID)• Tubo-ovarian Abscess (TOA)• Endometriosis• Ruptured or Hemorrhagic Ovarian Cyst• Adnexal Torsion• Uterine Fibroids• Ectopic Pregnancy

Pelvic Inflammatory Disease (PID)

• Inflammation and infection of the upper female genital tract, including the cervix, fallopian tubes, and uterus.

• Peritonitis also may be present. • Early diagnosis and treatment to prevent long-

term morbidity is key. • An episode of PID can cause recurrent/chronic

PID, chronic pelvic pain, ectopic pregnancy, infertility.

PID

• Ascending infection from the lower genital tract. – Neisseria gonorrhoeae, – Chlamydia trachomatics, – Diptheroids, – Gardenella vaginalis, – Mycoplasma genitalium, – Bacteroides, – Anaerobes, – Streptococci

• > 50% cases have more than one organism isolated

PID

• Symptoms/signs mimic that of appendicitis due peritoneal irritation and can often be vague/ misleading

• Diagnosis missed in up to 35% of patients. • Mucopurulant cervical/vaginal discharge is

present with PID

PID- CDC Diagnostic Criteria• Minimal Dx Criteria-

– Pelvic or lower abdominal pain AND – CMT OR uterine tenderness OR adnexal tenderness

• Additional criteria:– oral temperature >101 F– Cervical/vaginal mucopurulent discharge– WBC on microscopy of vaginal secretions– Elevated ESR– Elevated CSR– Documented gonorrhea/chlamydia cervical infection

• Most specific– Endometrial biopsy showing endometritis – Radiographic imaging showing thickened fluid filled tubes indicative of

infection– Laparoscopic abnormalities consistent with PID

PID

• Ultrasound– Transvaginal preferable – Uterine enlargement/thickened endometrium – Ovarian enlargement (reactive inflammation)– Edematous distended fallopian tubes with

hypervascularity on Doppler US• CT scan– Pelvic inflammation and fat stranding, indistinct

tissue planes.

PID- Ultrasound

Ovary

Dilated fallopian tube

PID- CT scan

Right side , normalLeft side, thickened/inflamed tubal wall

PID- treatment

• Outpatient: Ceftriaxone 250 mg IM PLUS Doxycycline 100 mg PO BID x 14 days +/- Metronidazole 500 mg PO BID x 14 days

• Inpatient: – A: Cefoxitin 2 g IV q 6 hours PLUS Doxycycline 100 mg PO/IV

q 12 hours– B: Ampicillin/Sulbactam 3 g IV q 6 hours PLUS Doxycycline

100 mg PO/IV q 12 hours • Diagnostic laparoscopy vs exploratory laparotomy- If

diagnosis is unclear ( i.e. PID vs appendicitis vs TOA), or no improvement with antibiotics

PID on laparoscopy

Fitz High Curtis

• Occurs with pelvic inflammation of PID spreads to right upper quadrant via right paracolic gutter and involves peritoneal surface of liver.

• Violin-string adhesions, typically encountered during laparoscopy, typically laparoscopic cholecystectomy

Fitz High Curtis

Tubo-Ovarian Abscess (TOA)

• 35% of women with PID, 20-40 years old, small percentage postmenopausal.

• 2/3 are unilateral- may lead to misdiagnosis of appendicitis if on right side.

• Initial insult to the female genital tract- inoculation and destruction of fallopian tube epithelium a purulent exudate with low oxygen environment favorable for anaerobic organisms.

• Inflammatory response induces edema, ischemia, and necrosis of fallopian tube.

TOA

• Surrounding structures may become involved in the expanding inflammation and walled off abscess, including ovary, round ligament, broad ligament, contralateral fallopian tube and ovary, appendix, bowel, and bladder.

• With expansion, rupture of TOA can occur. • TOAs can be the result of non- gynecologic

disease, including diverticulitis, appendicitis, inflammatory bowel disease, and surgery.

TOA• Polymicrobial:

– E. coli, – Bacteroides– Peptostreptococcus– Enterococcus– Klebsiella– Staphylococcus– Streptococcus– H. influenza.

• N. gonorrhoeae and C. trachomatis are rarely cultured from TOAs.• Anaerobic bacteria are present in 60-100% of TOA cultures.

TOA

• Lower abdominal pain (acute vs chronic), nausea/vomiting

• +/- fevers/chills- up to 50% of patients are afebrile • If bowel is involved- anorexia/diarrhea • Leukocytosis- present but not reliable indicator • Palpable abdominal/pelvic mass, rebound

tenderness/guarding• CMT, mucopurulent discharge, vaginal

discharge/abnormal bleeding

TOA- Imaging

• Ultrasound- sensitivity > 90% for diagnosis. – Transabdominal- larger field of view for identifying adnexal

masses.– Transvaginal- detailed view of pelvic anatomy and

vasculatyure. • Appear complex, multilocular, cystic with thickened

walls and internal echoes/debris. • Tubal and ovarian architecture disordered with

destruction of planes between the ovary and developing abscess.

• Cogwheel sign- thickening of endosalpingeal folds.

TOA- Imaging

• CT scanning if diagnosis is unclear- septated tubular structure with thickened walls.

• Hydronephrosis/hydroureter may be seen when surrounding tissue is involved with the inflammation.

• Gas bubbles within the fluid collection- highly specific for TOA

• TOA vs. appendicitis- TOA was highly associated with appearance of abnormal ovary, peri-ovarian fat stranding, small bowel and recto-sigmoid thickening, and free fluid in the pelvis.

TOA on US

TOA on CT

Appendicitis on US

Appendicitis- CT Imaging

TOA- Treatment

• Treat infection and preserve fertility• Mainstay of therapy is antibiotics +/-

additional drainage procedures ( image guided transabdominal or transvaginal approach)

• Parenteral antibiotics until 48 hours afebrile; continuation of oral antibiotics for 14 days

TOA- Surgical Treatment

• 1) Concern for alternative surgical emergency i.e. appendicitis, cholecystitis, bowel obstruction/perforation

• 2) Failure of clinical response after 48-72 hours of medical therapy

• 3) Intra-abdominal rupture of TOA- emergent surgery warranted due to hemodynamic instability, sepsis, multi-system organ failure

TOA on laparoscopy

Endometriosis

• Defined as presence of endometrial glands and stroma outside uterine cavity.

• Most accepted theory- development is retrograde menstruation. Other theories include coelemic metaplasia of endometrial tissue with lymphatic spread, and transformation of embryonic rests.

Endometriosis

• Prevalence - 7-10% in general population; up to 50% in infertile women

• 60% of women with dysmenorrhea, 87% of women with CPP

• Symptoms- dysmenorrhea, dyspareunia, CPP, pain with ovulation, micturition, defection

• Risks- early menarche, short menstrual cycles, reduced parity, heavy bleeding

• Increased risk- tall /thin women, excess alcohol and caffeine

Endometriosis

• Most common location of endometrial implants is the ovaries, followed by deep/central pelvis and vesico-uterine pouch

• 60% of Stage IV disease involves intestinal tract (rectum, sigmoid, colon, appendix, small bowel)

• With Stage IV disease- pain mediated by deep infiltrating endometrial lesions in muscular propria of surrounding organs

Endometriosis Treatment

• 1st line- NSAIDs and hormonal therapy • If pain is refractory, surgical intervention is

warranted, with laparoscopic ablation or removal (preferred) of endometrial implants

• With significant bowel/bladder involvement, laparotomy may be required

Endometriosis

• MRI- superior for detection of endometriomas- hyperintense signal of T1 weighted imaging or hypodense signal of T2 imaging

• CT- endometrioma appears as cystic mass with hyderdense clot within

• US- used to assess endometrioma involving ovary- hypoechoic cystic structure

Endometrioma on MRI

Endometrioma on US

Endometriosis on laparoscopy

Catamenial pneumothorax

• Recurrent pneumothorax occurring within 72 hours of onset of menses.

• SOB, CP, cough; usually RIGHT sided • Manifestation of thoracic endometriosis, likely

via transdiaphragmatic lymphatic/vascular transplantation of endometrial tissue

• Confirmed by presence of endometrial glands and stroma within pleura or diaphragm

Ruptured/Hemorrhagic Ovarian Cysts

• Most common- functional cysts, including corpus luteal cysts/ follicular cysts, which are more prone to rupture due to increased vascularity as part of the menstrual cycle

• Rupture typically occurs between 20-26 days of menstrual cycle (i.e. luteal phase, after ovulation has occurred)

Ruptured/Hemorrhagic Ovarian Cysts

• Mittelschmerz- sensation of pain and release of peritoneal fluid associated with physiologic rupture of corpus luteum, cyst during ovulation

• Ruptured cyst- most commonly right sided• Usual symptoms- acute pain, vaginal bleeding,

nausea/vomiting, shoulder tenderness• If associated with massive hemorrhage- signs of

circulatory collapse

Ruptured/Hemorrhagic Ovarian Cysts

• Ultrasound- thin wall, anechoic; with hemorrhage and clotting of blood- internal echoes appear with fluid and debris

• With massive hemorrhage- free intraperitoneal fluid present, while cyst itself is collapsed

Hemorrhagic Ovarian Cysts

Ruptured/Hemorrhagic Ovarian Cysts

• Hemodynamically stable- conservative management, analgesia, observation

• Unstable- emergent surgical intervention, even if diagnosis is uncertain

• If active/uncontrollable bleeding present- oophorectomy recommended; otherwise, conservative management with preservation of ovary is preferred

Ovarian Torsion

• Partial/complete twisting of adnexa around its vascular pedicle ( infundibulopelvic ligament and tubo-ovarian ligament)

• Vascular and lymphatic obstruction results, leading arterial occlusion and ovarian necrosis

• Right adnexa most commonly involved, possibly due to longer utero-ovarian ligament on the right vs. decreased mobility of left adnexa due to presence of sigmoid colon

Ovarian Torsion

• Commonly associated with ovarian mass (cyst, neoplasm, etc) as a fixed point around which adnexa may twist

• Previous pelvic surgery also increases risk, likely due to post surgical adhesions around which adnexa can twist

• Patients with ovarian hyperstimulation syndrome (due to assisted reproductive technology) also at increased risk

Ovarian Torsion

• Acute pelvic/abdominal pain; prolonged pain associated with high risk of necrosis

• Nausea, vomiting, dysuria, urinary retention, frequency, urgency

• Low grade leukocytosis/fever less common • Peritoneal signs

Ovarian Torsion

• Ultrasound- gold standard • Enlarged ovary (>5 cm) with edema• Absent arterial/venous flow is highly specific

for torsion • Pelvic free fluid present with

infarction/hemorrhage

Ovarian Torsion

No Doppler Flow

Ovarian Torsion

“Whirlpool sign”

Ovarian Torsion

• Preferred surgical treatment- laparoscopic detorsion with salvage of adnexa

• Oophorectomy warranted if ovary appears necrotic, ovarian mass present, or there is evidence of peritonitis

• If ovary is salvageable, consider ovarian suspension to decrease likelihood of recurrence.

Ovarian Torsion

Ovarian Torsion

Ovarian Torsion in Pregnancy

• Adnexal torsion is the most common complication of an adnexal mass occurring during pregnancy, typically in 1st and 2nd trimesters

• If ovarian mass without torsion is noted, surgery is performed in 2nd trimester

• If torsion is present, surgery is warranted regardless of gestational age

Uterine Fibroids

• Most common pelvic tumor in women; consist of hormonally responsive smooth muscle cells, which can lead to progression during pregnancy or with hormonal contraceptive use, and typically regress after menopause

• Most common symptoms- abnormal vaginal bleeding, pelvic pain and pressure

• Hydronephrosis can occur with chronic impingement of ureter

Uterine Fibroids

Degenerating fibroids that have outgrown/lost blood supply can present as acute abdominal pain

Ultrasound- anechoic, irregular cystic spaces within the fibroid, indicating necrosis

Ectopic PregnancyDefined as any pregnancy outside uterine cavity, most commonly in the fallopian tube (ampulla> isthmus> fimbria), abdominal cavity, ovary, cervix, or uterine cornua

Typically occur between 6-10 weeks gestation, and is the leading cause of death during the 1st and 2nd trimesters of pregnancy

Ectopic Pregnancy

• Risk factors- previous ectopic pregnancy, history of PID, previous pelvic surgery, smoking, infertility, intrauterine device use

• Symptoms- pelvic pain, vaginal bleeding • Quantitative bHCG- initial test– if >1500 mIU/mL, pregnancy can be seen on

transvaginal US– If > 5000 mIU/mL, pregnancy can be seen on

abdominal US

Ectopic Pregnancy

• US evaluation- 1st evaluate if pregnancy is intrauterine; at 5 weeks gestation (corresponding to bHCG between 1000-2000 mIU/mL) a gestational sac should be visible

Ectopic Pregnancy

• With ectopic pregnancy- gestational sac/fetal pole +/- cardiac activity seen outside the uterine cavity

• Adnexal mass separate from ovary with empty uterus, free fluid in pelvis, tubal “donut” sign and “ring of fire” on Doppler ultrasound

Ectopic Pregnancy on US

Ectopic Pregnancy- “Ring of Fire”

Ectopic Pregnancy

• If unruptured and hemodynamically stable- can consider conservative management with medical therapy i.e. Methotrexate with follow up of serial bHCG levels at day 4 and day 7 after injection, and then weekly until negative

• If bHCG fails to decrease by 15% from day 4 to day 7 after MTX injection, consider additional MTX injection vs. surgery

Ectopic Pregnancy

• If ruptured, emergent surgery is indicated, especially if hemodynamically unstable

• Depending on degree of patient stability, surgical approach via laparoscopy (preferred) versus laparotomy, with salpingostomy versus salpingectomy

• Salpingectomy indicated with uncontrolled bleeding, severely damaged fallopian tube, large gestational sac (> 5 cm)

Ectopic Pregnancy

Appendicitis in Pregnancy• 1/800 - 1/1500 pregnancies, incidence slightly

higher in the second trimester • Appendiceal rupture occurs more frequently

in pregnant women, especially in the third trimester -possibly due to inconclusive symptoms/reluctance to operate on pregnant women delaying diagnosis and treatment; associated with higher risk of fetal loss (36% vs. 1.5%)

Appendicitis in Pregnancy

• Less likely classic presentation, especially in late pregnancy– More GI complaints– Leukocytosis is common with pregnancy

• Pain typically originates at McBurney's point regardless of the stage of pregnancy; however, location of the appendix migrates a few centimeters cephalad with the enlarging uterus

• In the third trimester, pain may localize to the mid or even the upper right side of the abdomen

Appendicitis in Pregnancy

• US- wide variation in the diagnostic performance during pregnancy; gravid uterus can interfere with visualizing the appendix and performing graded compression (particularly in the third trimester)

• CT imaging- when clinical findings and ultrasound examination are inconclusive and MRI is not available

Appendectomy in Pregnancy

• Open preferred if late gestation• Laparoscopic – slight left lateral positioning if 2nd trimester and

beyond– avoid cervical instrumentation– open entry techniques/ trocar placement under

direct visualization– limit intra-abdominal pressure to less than 12

mmHg

Cholelithiasis in Pregnancy

• Gallstones are more common during pregnancy- decreased gallbladder motility/increased cholesterol saturation of bile– Estrogen increases cholesterol secretion– Progesterone reduces bile acid secretion and slows

gallbladder emptying, promoting the formation of stones via biliary stasis

• In pregnant women with biliary colic, supportive care will lead to resolution of symptoms in most cases, but the symptoms frequently recur later in pregnancy

Cholelithiasis in Pregnancy

• 1st episode - supportive care vs. cholecystectomy (laparoscopic if in 1st/2nd trimesters)– low risk of fetal mortality and high risk of disease

relapse/need for urgent surgery later in pregnancy. • Acute cholecystitis cholecystectomy – If near term- conservative management is

preferable as surgery is technically difficult, with plan for cholecystectomy 6 weeks postpartum

The End!Questions?