A 72 year old female was admitted from the emergency department with a five day history of abdominal pain, and markedly abnormal blood tests; haemoglobin 8.1 g/dl, white count 11.2 × 106 /dl, urea 28.3 mmol/l, creatinine 409 μmol/l. Physical examination revealed a large abdomen, non-distended, with diffuse tenderness, no guarding and normal bowel sounds.
Her past medical history was significant in that she was under haematological review for chronic normocytic, normochromic anaemia. This had been present for at least 20 months, and had been investigated with upper and lower gastrointestinal tract endoscopy, blood tests and ultrasound scanning all of which had been unremarkable.
There had also been one previous admission for acute abdominal pain 30 years earlier, and she had undergone laparotomy on the night of admission. Surgery revealed an enlarged right ovary with multiple solid areas, with rupture into the broad ligament. A total hysterectomy and bilateral salpingo-oophorectomy were performed. Histology revealed a mainly solid, large granulosa cell tumour of the ovary, with acute rupture. She was discharged uneventfully, and had not been followed up.
In the current admission, she was admitted for further investigation, and underwent a abdomino-pelvic contrast CT scan the next day. This revealed a large pelvic mass causing compression of the right ureter, and a right hydronephrosis (Figure , arrow).
The next day, she developed nausea, vomiting and colicky abdominal pain, and a plain abdominal radiograph was ordered. This revealed dilated small bowel loops, and a diagnosis of small bowel obstruction was made (Figure ). She did not respond to conservative management, and developed signs of small bowel strangulation after 24 hours.
At laparotomy, the terminal ileum was gangrenous in several places, and found to be tethered to a focal organised haematoma arising from a large retroperitoneal cystic mass behind the bladder. There was no blood elsewhere in the abdominal cavity.
The retroperitoneal mass was incised, with the resulting release of a haematoma of around 1 litre in quantity. This was evacuated from the cyst, together with a necrotic lesion in its centre, and sent for histology. A small bowel resection was performed, drains inserted and the abdomen closed.
She made an uneventful recovery, with full resolution of her renal function, and anaemia.
Subsequent histology revealed a sex cord – stromal tumour of ovary, characterised as a poorly differentiated granulosa cell tumour. The small bowel was also involved by tumour. An immunohistochemical review of her original tumour from thirty years prior was performed, and confirmed that a recurrence of the original lesion had occurred.
She was referred to a specialist oncological centre for further management and presently remains asymptomatic and disease-free.