A 50-year-old woman presents with 4 days of abdominal pain, nausea, vomiting and inability to open her bowels.
On examination she has a paraumbilical hernia with a distended abdomen, consistent with a small bowel obstruction.
A CT abdomen is performed
Describe and interpret the CT scan
This CT has two critical findings.
Firstly, there is an incarcerated umbilical hernia with obstruction of the herniated small bowel.
There is a loop of bowel narrowed at two segments at the abdominal wall defect in keeping with closed loop obstruction (also seen in case 61).
There are no features of bowel necrosis as there is normal enhancement of the bowel wall.
There is also a huge abdomino-pelvic mass. The beak-like (also described as claw-like) appearance of the lesion along the fundus of uterus suggests origin from the uterus. The lesion is solid with some internal calcification.
Part of the subsequent work-up for this patient involved assessing tumour markers. The CA-125 was 100 (ref 0-35U/ml).
With an elevated CA-125 and with such a large uterus with calcification and areas of hypervascularity, there was concern for uterine malignancy. An elevated CA-125 can be caused be several malignancies including ovarian, fallopian tube, peritoneal and endometrial.
However, it can also be elevated by menstruation and by fibroids.
Due to the possibility of this being malignant, this patient had a laparotomy the following day. This identified a large multi-fibroid appearing uterus, with normal ovaries and fallopian tube.
She had a total abdominal hysterectomy, bilateral salphingo-oopherectomy and para-umbilical hernia repair with an uncomplicated post-operative course and went home two days post-op.
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Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).