59. Abdominal distension Flashcards
DDX abdominal distension
Gynaecological
Fibroids
Ovarian cyst
Ovarian cancer
Gastroenterology
Ascites
IBD
IBS
History abdominal distension
Examination abdominal distension
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What are fibroids
Fibroids are benign smooth muscle tumours of the uterus.
Risk factors for fibroids
race, increasing age
Occur in around 20% of white women
Occur in 50% of black women
later reproductive years.
Typical history and exam fibroids
PC: menorrhagia, prolonged menstruation (>7days), abdominal pain worse during menstruation, bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, e.g. frequency, may occur with larger fibroids, subfertility, deep dyspareunia, reduced fertility
o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus
PC: may be asymptomatic, menorrhagia (may result in iron-deficiency anaemia)
bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, frequency, subfertility
fibroids
investigation ?fibroids
Diagnosis
transvaginal ultrasound
hysteroscopy?
Management asymptomatic fibroids
no treatment is needed other than periodic review to monitor size and growth
Management of menorrhagia secondary to fibroids if fibroids <3cm
- levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity - Non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid
- Hormonal: combined oral contraceptive pill or oral progestogen eg norethisterone
- injectable progestogen
Management of menorrhagia secondary to fibroids if fibroids >3cm
- Refer to secondary care
- In meantime : non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid
Considered in secondary care:
1. levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity
- Medical treatment to shrink/remove fibroids
- GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment - Surgical treatment to shrink/remove fibroids
- myomectomy if wanting to preserve fertility
- hysteroscopic endometrial ablation
- hysterectomy
- uterine artery embolization
Side effects of GnRH agonists
menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density
Examples of GnRH agonists
GoseRelin
leuprorelin (brand name Lupron) and triptorelin (brand name Decapeptyl), goserelin (zoladex)
Mechanism of action GnRH agonists
Prolonged activation of GnRH receptors by GnRH leads to desensitization and consequently to suppressed gonadotrophin secretion. This is the primary mechanism of action of agonistic GnRH analogues.
Prognosis and complications of fibroids
- regress after menopause as estrogen driven
- red degeneration particularly in pregnancy
- subfertility
- iron deficiency anemia
What are ovarian cysts?
A cyst is a fluid-filled sac. Functional ovarian cysts are related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women.
typical history ovarian cyst
PC: asymptomatic, bloating, fullness in abdomen, pelvic pain (acutely severe pain in ovarian torsion, haemorrhage or rupture)
typical history ovarian cancer
PC: asymptomatic, bloating, fullness in abdomen, pelvic pain (acutely severe pain in ovarian torsion, haemorrhage or rupture)
Red flags: Abdominal bloating, Reduce appetite, Early satiety , Weight loss, Urinary symptoms, Pain, Ascites, Lymphadenopathy, change in bowel habit - symptoms of IBS
Risk factors: post menopausal, older age, BRCA 1 or BRCA 2, many ovulations (early menarche,late menopause, nulliparity), smoking, obesity
Protective factors: COCP, breast feeding, pregnancy
red flags for ovarian cancer
Red flags: Abdominal bloating, Reduce appetite, Early satiety , Weight loss, Urinary symptoms, Pain, Ascites, Lymphadenopathy, change in bowel habit - symptoms of IBS
risk factors for ovarian cancer
Risk factors: post menopausal, older age, BRCA 1 or BRCA 2, many ovulations (early menarche,late menopause, nulliparity), smoking, obesity
Protective factors: COCP, breast feeding, pregnancy
Plan ?ovarian pathology
1) Consider for 2ww, do CA-125 if post menopausal
Refer directly if physical exam reveals : ascites, pelvic mass, abdominal mass
If exam normal → measure CA-125 (particularly important if over 50 and red flags) → if > 35IU/ml → arrange urgent USS → if USS suggestive of ovarian ca → 2ww to gynae
1) USS if pre-menopausal and no red flags
Management of ovarian pathology based of USS
Pre-menopausal with simple cyst <5cm don’t need any further investigation
Pre-menopausal with simple cyst 5-7 cm - routine referral to gynae for annual USS
Pre-menopausal with simple cyst>7cm - consider MRI or surgical evaluation
Women <40 with complex ovarian mass: test tumour markers for a possible germ cell tumour: lactate dehydrogenase (LDH), alpha-fetoprotein (a-FP), human chorionic gonadotrophin (HCG) → referral to gynae for biopsy and ?surgery
Postmenopausal simple cyst<5cm, USSmonitoring every 4-6 months
Complex cyst - biopsy
USS ovaries : Multi-loculated
complex, could be ca –> biopsy
USS ovaries : “Thin walls and no internal structures”
Likely benign follicular cyst
USS ovaries: Solid tumour consisting of bundles of spindle shaped fibroblasts
ovarian fibroma
USS ovaries “Signet ring”
Krukenberg tumour (metastasis from another site)
What features suggest a malignant over a benign cystic neoplasm?
large cystic mass
thick irregular walls and septa
papillary projections
large soft tissue component
ascites
evidence of invasive spread or adenopathy
Causes of raised CA-125
Ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy
What is the risk of malignancy index
Menopausal status
Ultrasound findings
CA125 level
Management of ovarian cancer
usually a combination of surgery and platinum-based chemotherapy
what is the most common type of ovarian cyst
follicular cyst
physiology and prognosis follicular cyst
Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.
They typically disappear after a few menstrual cycles
how do follicular cysts appear on USS
“Thin walls and no internal structures”
what is a corpus luteum cyst?complication?
during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst
more likely to present with intraperitoneal bleeding than follicular cysts
what type of germ cell are you aware of?
dermoid/teratoma
what is the most common benign ovarian tumour in women under 30
teratoma
what is a teratoma
Most common benign ovarian tumour in women under 30
Lined with epithelial tissue so may contain skin, hair and teeth
More risk of torsion
what are teratomas more at risk of compared with other ovarian cysts/tumours
torsion
what types of benign epithelial ovarian tumors are you aware of
- serous cystadenoma
- mucinous cystadenoma
what is a serous cystadenoma
Most common benign epithelial tumour which bears resemblance to most common type of ovarian ca (serous carcinoma)
what is a mucinous cystadenoma
Second most common benign epithelial tumour
Typically large and become massive
IF rupture occurs, may cause pseudomyxoma peritonei
what sex cord-stromal benign tumours are you aware of?
ovarian fibroma
what is an ovarian fibroma
Benign sex cord-stromal tumour
Solid tumour consisting of bundles of spindle shaped fibroblasts)
Associated with Meig’s syndrome : triad of: ovarian fibroma, pleural effusion, ascites. Management involves removal of the tumour - causes resolution of effusion and ascites
how does an ovarian fibroma appear on USS
Solid tumour consisting of bundles of spindle shaped fibroblasts
what is meigs syndrome? management?
triad of: ovarian fibroma, pleural effusion, ascites.
Management involves removal of the tumour - causes resolution of effusion and ascites
Most common origin of ovarian cancers
Around 90% of ovarian cancers are epitlelial
most common type of ovarian cancer
serous carcinoma
what are the stages of ovarian cancer
Stage 1
Tumour confined to ovary
Stage 2
Tumour outside ovary but within pelvis
Stage 3
Tumour outside pelvic but within abdomen
Stage 4
Distant metastasis
examination findings fibroids
o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus
