Presentation
20/40 pregnant, acute right lower abdominal pain.
Patient Data
The appendix has a normal appearance and is located medial to the cecum and proximal ascending colon. Abutting the right anterior wall of the uterus, there is an ovoid heterogeneous mass with mixed internal signal that is suggestive of fluid and blood. Some fluid is present around the lesion. It appears distinct from the right ovary.
At the time of reporting, the normal appendix was not recognized and the mass was suggested to be an appendix phlegmon. Review in a meeting a short time later raised the possibility of the lesion being a degenerating fibroid. In order to clarify the situation, the patient was counseled about the risks and benefits of a CT.
The CT confirms that the appendix is normal, and a heterogeneous mass abutting the uterus with a small volume of adjacent free fluid. Physiologic left side hydronephrosis is also noted, with compression of the ureter between the uterus and the left psoas muscle.
Case Discussion
Following the CT, it was highlighted that ultrasound imaging acquired prenatally had shown a fibroid in the same location as the mass seen on the MRI and CT. The final diagnosis was of a degenerating fibroid, and the patient proceeded to term labor with no further intervention required. Red or carneous degeneration of fibroids is thought to be the most common form of degeneration of a leiomyoma during pregnancy. The case highlights the importance of reporting with all available imaging history. Careful review of the MRI by specialist radiologists also enabled more confident identification of the appendix.