Post-uterine artery embolisation of a large leiomyoma: uterine ischaemia, necrosis, endometritis and septic peritonitis

Case contributed by Dr Mohammad A. ElBeialy

Presentation

Severe generalized abdominal pain with nausea and vomiting. History of uterine artery embolization for a large fibroid 4 weeks earlier. The patient experienced mild lower abdominal pain after the procedure that persisted and progressively increased.

Patient Data

Age: 39 years
Gender: Female

Large heterogeneous non-enhancing 17 x 13.2 x 17.3 cm uterine fundal mass lesion with streaks of air density, suggestive of infarcted uterine fibroid with necrotized component and breached surface (discontinuity) mainly in the fundal region is noted with leakage of component including air and fluid to the abdominal cavity suggestive of likely ruptured necrotized fibroid.  

Moderate amount of rather dense ascites and free intra-peritoneal air (pneumoperitoneum) is noted with relative thickening of the peritoneal wall and mild enhancement.                                

A large non-enhancing uterine fibroid with heterogeneous texture and signal voids consistent with gas loculi.  The uterine wall at the fundus of the uterus overlying the lesion is markedly thinned with focal disruptions. Large amount of ascites is noted with evident restricted diffusion demonstrating hyperintense DWI and low ADC signal suggestive of pus. Evidence of pneumoperitoneum is noted with air-fluid level as well as diffuse uniform thickening and enhancement of the peritoneal wall. Bilateral small amount of pleural effusion with mild bilateral basal atelectasis. Incidentally noted is a sliding para-oesophageal hiatus hernia.
 

Case Discussion

Status post-uterine artery embolization  with necrotizing and infarcted myometrial fibroid that is complicated by endometritis, uterine ischemia, focal disruption of the uterine wall and peritonitis with moderate amount of peritoneal fluid collection; likely pus.

At surgery, two liters of pus were drained and myomectomy was done.

 

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Case Information

rID: 46959
Case created: 26th Jul 2016
Last edited: 12th Sep 2016
System: Gynaecology
Inclusion in quiz mode: Included

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