Presentation
Acute left pelvic pain with signs of hypovolemic shock including tachycardia, hypotension, and fainting. History of previous left ovarian torsion that was salvageable at laparoscopy
Patient Data
US study shows:
- enlarged left ovary, preserved ovarian arterial and venous vascularity, a well-defined ovarian complicated cystic lesion (C) measures 40 x 33 mm with thick wall and internal trabeculations, the ovary is seen surrounded with an echogenic collection (H)
- mild free collection in the Cul de sac
- normal right ovary
- normal uterus
CT study shows a dense collection surrounding the left ovary, density measures about 66 HU, suggesting clotted blood "sentinel clot sign".
The left ovary is mildly enlarged shows a well-defined ovoid small cystic lesion that measures 2.5 x 1.5 x 1.5 cm, elicits intermediate to high signal intensity in T1 and low signal in T2 with thick marginal enhancement in the post-contrast study. The ovary appears also enhanced. It is seen circumferentially surrounded with a collection that measures about 3.5 x 4 x 3 cm elicit intermediate to high signal intensity in T1 and low signal in T2 with no enhancement in the post-contrast study. Mild free collection is seen at the cul de sac.
The first video shows the free blood collection in the pelvis and the second one shows the hematoma surrounding the left ovary and cystectomy for the ruptured hemorrhagic cyst.
Case Discussion
Ruptured ovarian cysts and hemorrhagic ovarian cysts are the most common causes of acute pelvic pain in an afebrile, premenopausal woman presenting to the emergency room.
The presence of sentinel dense blood clot (45-70 HU) is a helpful sign in CT to predict the source of bleeding "sentinel clot sign".
The following are the mean CT densities of fluid and blood
fluid: 0-10 HU
acute blood: 30-45 HU
clotted blood: 45-70 HU
from 10-30 HU: may be seen in old blood or anemic patients
Ruptured ovarian hemorrhagic cysts are usually treated conservatively in premenopausal women unless evidence of hypovolemic shock.
Additional contributors; Dr. Somia Elbadawy and Dr. Samar Fathy.
Laparoscopic photos are courtesy of Dr. Amro Abdelhalim, the gynecological surgeon.