بهار سوج
زاگرسیا زیبای طبیعت
91
CPCBy :
Dr. Sarraf MD
Dr. Akbarzadeh Md
Dr. Khalili , Dr. Karami , Dr. Sabouri , Dr. Safari Poor
CASE 1رضایی صغری
30 Y/O
G1L1 (1PC/S)
LMP: 1.7.92
C.C. : generalized abdominal pain
The Pt transfered from Lamerd hospital
on admission the pt has following positive findings:
Fever
Nausea & vomiting
Anorhexia
Spotting
OB HX: Primary infertility for 14
years G1: C/S
GYN HX: Mense: regular
Mearch: 13 year-old Contraception:
Past M. HX.: No significant findings
Past surgical HX.: PC/S
Laparascopic procedure that failed due to sever adhesion bands followed by laparotomy for ovarian cystectomy (R/O Endometrioma) about 3years ago Pathology report: simple seros
cyst & leuteal cyst
Phsycal Examination V/S:
T:??! P.R.: 100/min
B.P.: 100/60 mmhg R.R.: 18/min
HEENT: No significant
Heart: No significant
Lung: No significant
Abdomen: Mild tenderness in both lowe guardant &
adenexa No guardig
Rebound tenderness positive
V/E: Left adenexa palpable mass detected (about 15
cm)
LAB DATACBC:
6.7.92
WBC: 11900 HB: 10.7
PLT: 560000
7.7.92
12500
9.8
439000
13.7.92
21800
8.4
664000
B/C: Negative
U/A:
Normal
U/C: Negative
PT, PTT, INR : NL
LFT: NL
BHCG: Negative
Viral marker:
Negative
Bun, Cr, Electrolyte: NL
Amylas: NL
LDH: 472
General surgeon consultation
Mild generalized Abd. tenderness with out guarding & rebound tenderness and recommended medication ( metronidazole+ cefteriaxon ) and observation ( check CBC , V/S and serial examination )
PAP Smear: NL (18.7.92)
Abdomino-Pelvic sono.: 9.4.92 By Dr. Paidar Mohammad-Reza; A 82x74 mm cyst with mild
lobulated border & a thin shelf like septum is seen in Rt ovary. Lt ovary is enlarged with 3 cyst, the largest is about 40 mm .
recommendation: correlation with previous sono. And MRI with and with out contrast.
6.7.92 By Dr. Naserei; Moderat free fluid is seen in Abdomino-pelvic cavity. For brter evaluation TVS was done.
TVS:
Uterus: nl size & shape & parenchymal echogenicity grossly with out evidence of SOL
Rt ovary: nl size & a large cystic structure is seen about 81x56 mm, with echogenic content & some increased wall thickness infavor of hemorrhagic cyst, however endometrioma is also in diferntial DX.
Lt ovary: nl size & shap parenchymal echogenisity ,Smal cystic structure (16x9 mm) seen & some free fluid in pelvic cavity. So according to the mentioned finding of rupture ovarian cyst should be inconsideration.
Abdomino-Pelvic MRI: 11.7.92 By Dr. Rasekhei; both ovaries are enlarged and containing
multiple large cystic lesiont. There are associated with thick septal and proteinecious content. The above mensioned finding are associated with large amount of ascitis and peritoneal thickening infavor of bilateral ovarian serous adenocarcinoma and peritoneal seedig of malignancy.
Abdominal Tap (11.7.92):
cytology: no malignant cell Culture : positive (E-coli )
EUA + D&C (16.7.92 ): A mobile mass like with uterous 18 wks
in mid part of abdomen Pathology report : no significant
pathologic change in prolifrative phase
Colonoscopy & Endoscopy: NL
OPERATION21.7.92
Pre op DX.: Bilateral adenexal mass
Post op DX.: Dens intra abdomino-pelvic adhesion of small &
large bowel to both adenexa and pelvic floor + bilateral tubo-ovarian abscess + bilateral hydrosalpynx +multiple collection between bowel loop + obliterated posterior coldesac
Kind of operation : EXPLOTORY LAPARATOMY + release of
adhesion + dranage of abscess + supra cervical hysterectomy + bilateral salpingo-oophorectomy
بهار یاسوج 91سد
CASE 2پری ساخت عایشه
62 Y/O
G4D3L1
LMP: Menopause since 20 year ago
C.C. :abdominal pain & protrusion
Date of admission: 27.1.92
The pt presented with c.c. of Abd. Pain
and... ?
Present illness:
?!
!
?
OB HX. : All NVD
GYN HX. : Menopause since 20 year ago
Past Med. HX. : HTN, Thyroid problem, Cardiac problem, DM,
Renal stone
Past Surgical HX. : negative
P/E
V/S: T.: 37.5 BP: 120/70 mmhg HR: 82/min RR: 16/min
HEENT: no significant
Heart: no significant
Lung: no significant
Abdomen:
!???
Lab data: CBC WBC: 11200 HB:11.8 PLT: 462000
BUN, Cr, Electrolyte, LFT, U/A, S/E All not significant PAP smear: normal
Tumor marker: CA-125: 831.5 (28.2.92)
Abdomino-pelvc sono.(27.1.92): huge large hypoechoic mass with some several cystic changes that occupy pelvic cavity and extended to umblical area with moderate free fluid in pelvic cavity. Serous cyst adenocarcinoma should be considerd. CT scan recommended. Spiral CT scan(29.1.92): large heterogenous echogenic
mass lesion (15x14x16 cm) arising from uterus highly suggestive for malignant uterin mass + moderat free fluid and ascities.
Abdominal Tap : cytology suspicious to malignancy
Endoscopy & colonoscopy: normal
The pt received 6 course of chemotherapy ( Taxol + Carboplatin ).The last one was in 1.7.92 .
CA-125831.5
(28.2.92)
171.5(18.4.92)
18.3(23.5.92)
25.3(17.6.92)
7.2(28.7.92)
Operation
Pre op. DX: Ovarian cancer on neoadjuvant chemotherapy
Post op. DX: Peritoneal seeding on anterior pelvic wall + Lt
ovarian mass (4x5 cm) + adhesion on Lt ovarian fossa & posterior coldesac and rectosygmoid colocn with involvment of capsul
Kind of operation: Exploratory laparotomy + TAH + BSO +
peritoneal washing + release of adhisions + Lt ovarian mass resection + partial omentectomy + Liver & diaphragmatic smear that sampels sent to pathlogy
بهار یاسوج91
CASE 3اینالو بیگ بی بی
52 Y/O
G7L6D1(two PC/S)
LMP: 27.7.92 , Irregular
C.C.:abdominal protrusion & menomtrorhagia
The pt presented with c.c. of Abd. Pain and protrusion ,also she has AUB that abdomiopelvic sono. was done for him (27.1.92) that abdominal mass detected (206x191x124 mm) therefore CT scan &MRI recommended for him.
MRI was done that abdomen was normal and pelvic had intramural myoma (2.5x3.5 cm) in fundal part of uterus also multiloculated mass with heterogeneous signal on Lt side of uterus associated with pressure effect was seen.
Present illness:
Open and close operation was don for him with imp. of of myoma in Jahrom hospital by Dr Motreb (7.3.92) deu to large and congess mass with sever adhesion of bowel loop to mayoma and suspicious to malignancy the Pt refered to shiraz.
OB HX. : G1 G6 :NVD G6 G7 : C/S
GYN HX. : Mens irregular Contraception TL since 18 years ago
Past Med. HX. :
Past Surgical HX. : 2times C/S Laparatomy (large myoma)
P/E
V/S: T.: 37 BP: 120/70 mmhg HR: 80/min RR: 15/min
HEENT: no significant
Heart: no significant
Lung: no significant
Abdomen:
Vaginal /E: uterus 25-26 wk, others: nl
!???
Lab data: CBC:
WBC: 9700 HB: 9.3
PLT: 283000
PAP smear: normal (8.3.92)
Tumor marker: negative (21.5.92)
Mamography: normal
Colonoscopy & endoscopy: normal (25.3.92)
Trucut biopsy: Liomyoma with area of
hyalinization with out any atypia or myotic activity
Operation7.8.92
Pre op. DX: Huge pelvic mass + myomatus uterus
Post op. DX: Large uterus (26 wk) contained multiple
intramural & subserosal fibroma with dens adhesion to small and large bowel and abdominal wall.
Kind of operation: Exploratory laparotomy + TAH + BSO +
peritoneal washing + release of adhesions of small and large bowel to uterus
بهار 91یاسوج
CASE 4کارگر فاطمه
62 Y/O
Nulligravid
LMP: menopause
C.C.:abdominal pain
The pt presented with c.c. of Abd. Pain and protrusion since about 10 months ago that sonography and CT scan was done for him that detected a large mass in pelvic cavity
Present illness:
OB HX. : Nulligravid
GYN HX. : Menopause
Past Med. HX. : HTN
IHD
Past Surgical HX. : Negative
Drug HX. : Metoral, Enalapril, Nitrocantin
P/E
V/S: T.: 37.2 BP: 120/75 mmhg HR: 85/min RR: 14/min
HEENT: no significant
Heart: no significant
Lung: no significant
Abdomen:
Vaginal /E: Lt adenexal mass
uterus Normal
!???
Lab data: CBC , LFT, BUN, Cr, Electrolyte were normal PAP smear: normal (8.3.92)
Tumor markers:(29.4.92) CA-125: 264.8 U/ML
CEA : 1.1 ng/ML
CA19-9: 6.5
CA15-3: 66.7
Mamography: normal
Colonoscopy & endoscopy: normal
Biopsy(7.11.91): Papillary serous cyst
adenocarcinoma
The pt received 6 course of neoadjuvant chemotherapy , the last course 1n 12.4.92 .
Tumor marker: CA-
125(29.4.92)
264.8
(6.7.92)
672
Abdomino-pelvic sono.: (12.9.91) Large solid mass with sever ascites &
umblical hernia Abdomino-pelvic CT scan: (27.9.91)
Large lobulated mass( 12x10x8 cm) in Lt side pelvic cavity arising around Lt ovary with mesenteric seeding & sever ascites
Abdomino-pelvic sono.: (14.2.91) Necrotizing center solid mass(80x50
mm)in Lt ovary infavoer of serous cyst adenocarcinoma Abdomino-pelvic sono.: (16.5.92)
Large size necrotizing solid mass (12x9 cm) in Lt pelvic side
Operation(exploratory staging laparotomy)
21.7.92 Pre op. DX: Lt ovarian mass(papillary serous cyst
adenocarcinoma) Post op. DX: Large Lt ovarian mass(14x15cm) with dense
adhesion to rectosygmoid colon & small bowel + 4x5 cm umblical hernia
Kind of operation: Exploratory laparotomy + TAH + BSO +
peritoneal washing + release of adhesions of small and large bowel + partial omentectomy + Liver cytology