Integrata Ginecologia e Obstetricia (IGO)
Case Report
A Rare Presentation of Spontaneous Intraperitoneal Rupture of
Dermoid Cyst Presenting as Acute Gynecological Emergency:
A Case Report
Bharti Joshi1*, Neelam Aggarwal1, Vanita Suri2, Pooja SIkka1 and Seema Chopra1
Assistant Professor, Department of Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research Chandigarh, India
1
Professor and unit head, Department of Obstetrics and Gynecology, Government Medical College Chandigarh Sec-32, India
2
Copyright: © 2016 Bharti Joshi. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Spontaneous rupture of dermoidcyst (mature cystic teratoma) leading to acute abdomen is a rare event. Urgent surgical intervention is required after confirmation
of the diagnosis in order to prevent prolonged chemical peritonitis and its related complications. A young female who had presented with acute abdomen due
to ruptured dermoid is reported.
Key words: Dermoid cyst, Peritonitis, Rupture, Pouch of douglas, Acute
abdomen
Introduction
Dermoid cyst is a frequently encountered benign ovarian tumor
with reported incidence of 10-25% [1].They are slow growing, more
common in reproductive age group and notorious because of their
variable clinical presentation. They are generally symptomless but may
complicate leading to dreadful upshots if not treated adequately [2,3].
The most common complication of mature cystic teratoma is
torsion (15%) [4] but rupture can occur in 0.3-2% of cases [5]. Torsion
with infarction, direct trauma or prolonged pressure from pregnancy
or delivery are the proposed inciting events leading to dermoid
rupture as spontaneous breach in cyst wall is extremely rare because
of its thick nature.Acute and chronic peritonitis are the two clinical
presentations associated with intraperitoneal rupture of dermoid
cyst [6-8]. Sudden rupture of the tumor contents in abdomen cause
acute peritonitis and usually have favorable outcome after immediate
laparotomy followed by thorough lavage with oophrectomy of the
involved ovary. Chronic granulomatous peritonitis is the result of slow
leak from dermoid wall and may mimic peritoneal carcinomatosis
or tubercular peritonitis because of the characteristic small white
peritoneal implants, dense adhesions and variable ascites [9].This type
of peritonitis is more common and poses management difficulties due
to subsequent adhesions and its sequel.
Case Report
A 26 year old multiparous lady was referred to our institute with
complaint of pain abdomen and vomiting for past 8 days. There was
history of 6 weeks amenorrhea 2 months prior to this episode whereby
surgical MTP was done and she resumed her periods after 4 weeks.
On systemic examination she was found to be anemic and febrile.
Abdominal examination revealed distension with guarding and
rigidity and normal sized uterus with 8x6 cm tender mass was felt in
pouch of douglas during pelvic examination. Ultrasound done in our
own department showed normal sizes uterus with 8x 8 cm adnexal
mass just posterior to uterus with low level echoes with septated
Int Ginecolgia obstcia , 2016
collection in bilateral paracolic spaces and POD. A provisional
diagnosis of pelvic abscess was made and supported management
started. Patient was further subjected to CECT abdomen and pelvis
which reported a well defined 9x9x8 cm heterogeneous lesion in left
hemipelvis with presence of fatty attenuation areas, fat fluid level and
eccentric calcified soft tissue nodule. Ascites with multiple fat implants
and peritoneal enhancement was suggestive of ruptured dermoid with
chemical peritonitis.
An explorative laparotomy was undertaken. Abdominal cavity was
full of pus and cheesy material. Pelvis was sealed off and there was left
sided ruptured ovarian cyst of 8x9 cm adherent to gut loops and lateral
pelvic walls. Hair tuft was present inside the cyst confirming diagnosis
of dermoid .left salpingoophrectomy and thorough lavage was done
and patient recovered well in post-operative period. Histopathological
examination confirmed mature cystic teratoma.
Discussion
An accurate diagnosis of rupture ovarian dermoid requires high
index of suspicion, proper methodical approach and more aggressive
use of imaging modalities. In early period of rupture symptoms and
signs may simulate dyspepsia or gastroenteritis features. The presence
of ascites and discontinuity of the cyst wall on sonography, CT or
MRI is suggestive of rupture [11]. Computerized tomography is fairly
straightforward because this is 98% sensitive and 100% specific in
diagnosing dermoid as this modality can detect fat attenuation within
a cyst with or without calcification in the wall as in our index case
[1,10].
*Corresponding author: Bharti Joshi, Department of Obstetrics and
Gynecology Post Graduate Institute of Medical Education and Research
Chandigarh, India, Telephone: +919915166210; Fax: +919915166210; E-mail:
[email protected]
Received: October 08, 2016; Accepted: November 11, 2016; Published:
November 18, 2016
Volume 1(1): 4-6
Citation: Caseiro L, Regalo A, Esteves T (2016) Subchorionic Placental Cysts and its Controversial Management. Integrata Ginecologia e obstetricia 1: 101
Dermoid rarely may perforate into adjacent bladder, bowel and
vagina in addition to intraperitoneal rupture. Nader et all [11] recently
reported delivery induced rupture of dermoid following vaginal
delivery .Immediate surgical intervention remains the cornstone of
successful management however operative management of chronic
granulomatous peritonitis may be complex and challenging as there is
limited data available in published literature. Systemic corticosteroid
and immunosuppressive agent may improve postoperative recovery
in these cases.
Recollection of dermoid cyst kindred with glial seedling and
comprehensive perception of the images and of the adverse events
of ovarian teratoma areparamount to prevent misdiagnosis, to avoid
extensive surgery, and to achieve satisfactory outcome (Figure 1-3).
Figure 1: Adenexal mass
Figure 2: Sepated collection in paracolic and POD.
Figure 3: Sepated collection in paracolic and POD.
Int Ginecolgia obstcia , 2016
Volume 1(1): 5-6
Citation: Caseiro L, Regalo A, Esteves T (2016) Subchorionic Placental Cysts and its Controversial Management. Integrata Ginecologia e obstetricia 1: 101
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