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Suffer severe abdominal pain and vomiting. Ultra scan indicates large heterogeneous lesion. Cure?

Mar 2013
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Practicing since : 1998
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My daughter is 18 years girl studying Engineering and staying in college hostel. Her menstrual periods are normal and regular. Though she is underweight and weak in constitution, generally she is healthy with no previous medical history.

Last week she had severe pain ( 6th day of menstrual period )in the left lower abdomen. She had vomiting when tried any liquid or solid food for one day. She was put on drip. she suffered with discomfort in abdomen like gas .

I brought her home(small city) and consulted Dr. Gastro. Her Ultra Scan (abdomen ), (done on 10 th day) indicates that every thing is normal except

Large heterogeneous lesion (8.2X6.3Cm) with cystic component (5x 5.7 Cm) in POD right side --? Hemorrehagic right para ovarian cyst

Minimal ascitis

Left ovary is not visualized

Right ovary 3.4x3.4 cms normal in size echo texture

Her blood tests like cbp, sgpt, lipase etc are normal

Then we consulted Gynic ( an young doctor available in the same hospital) who prescribed some antibiotics. and pain relievers for one week. Also advised CAT-125 and results are awaited.

Please advise us along with following information
is there any requirement for immediate further check up by XXXXXXX specialist
is there any possibility for error in ultra sound scan.
what is the relation between pain in left side and cyst in right side
whether presence of gas is reason for not visualizing left ovary or what was found in POD could be ruptured left ovary

Posted Wed, 11 Sep 2013 in Women's Health
Answered by Dr. Aarti Abraham 33 minutes later
Brief Answer:

Detailed Answer:
Thanks for your query.
Let me answer your questions in the order in which you have posed them -
1. I think a XXXXXXX specialist should have a look at your daughter, as you do not seem to be convinced by the Gynecologist who appears to be quite junior. Also, as your daughter is still young and unmarried, the diagnosis should be confirmed by a XXXXXXX Specialist.
2. Generally, there cannot be an error on ultrasound, because such a large lesion cannot be mistaken. However, the diagnosis would be additionally confirmed by a CT scan. On any kind of radiological investigation, only the possibilities can be listed. Only by opening the abdomen and looking at it, confirmation is possible. Hence the first possibility is para ovarian cyst. This is a cyst arising from the structures that are present besides the ovary, near it, such as the fallopian tube, ligaments etc. The size of the lesion cannot be mistaken, so there is definitely a mass there .
3. The paraovarian cyst can cause twisting of the surrounding structures. It is called torsion. It can put pressure and strain on the nearby ligaments, and the bladder and bowel etc. It definitely could be responsible for the pain. The ovaries are located in the pouch of XXXXXXX that is the space situated BEHIND both ovaries. Hence a cyst present on the right side also could cause pain that could appear to be on the left.
5. One reason for not visualizing ovary could be gas. Other reason could be that the ultrasound was done abdominally, and the ovary is situated in the pelvis, and is small in young girls, and is best seen by a transvaginal ultrasound, often missed on abdominal scans. The third and most likely possibility is that the parovarian cyst is involving the left ovary, and is present in the POD, hence appearing to be right sided. This possibility can be confirmed by a second ultrasound, preferably transvaginal, and by a CT scan done together.

Now, my additional opinion -
Generally parovarian cysts are quite asymptomatic, and do not need any aggressive management.
However, in your case, it is haemorrhagic, that is , it might cause XXXXXXX bleeding at any time.
Also your daughter has had an incident of acute pain presenting as emergency already.
In such situations, it is advisable to undergo removal of the parovarian cyst. This is best done laparoscopically in young girls, for cosmetic reasons and because the post operative course is smoother when the surgery is done via laparoscope instead of opening the abdomen.
Take care, and please feel free to discuss further about this.
All the best.
Above answer was peer-reviewed by
Follow-up: Suffer severe abdominal pain and vomiting. Ultra scan indicates large heterogeneous lesion. Cure? 7 hours later
Thanks for the detailed answer
CAT results came and there normal (17)
Now she is ok. No pain or other problems now. But she is reluctant to take any further tests and asking to wait till semester holidays(Nov). She wants to go back to college
is it ok to postpone further tests upto Nov
As she would be staying in hostel, what are the alarming symptoms to act immediately
Answered by Dr. Aarti Abraham 2 hours later
Brief Answer:

Detailed Answer:
Hello again
Thanks for the appreciation.
Would you please elaborate on the CAT scan results - what do you mean by normal ?
Was there no cyst or mass seen on CAT scan ?
Would you please upload the result ( report only - not images ) on this page , so that I might be able to go through them ?
It is alright to postpone further testing till November, if the CAT scan is indeed normal.
She could experience extreme pain in emergency , fainting, dizziness, weakness, mild spotting or bleeding .
The main alarming symptom would be extreme pain - she would have to land up in emergency in that case.
take care.
Above answer was peer-reviewed by
Follow-up: Suffer severe abdominal pain and vomiting. Ultra scan indicates large heterogeneous lesion. Cure? 17 minutes later
Sorry. what was done, is blood test- CA-125(not CAT-125 as mentioned by me).The result is 17.47 U/ml. The doctor told me it is normal Range, probably due to cyst it is around 17, otherwise it would be below 5.She prescribed tablets Meprete for one month and advised Rpeat scan thereafter
Answered by Dr. Aarti Abraham 2 hours later
Brief Answer:

Detailed Answer:
The CA 125 would be generally normal, unless it is a malignant cyst, which is not the case.
You can consider taking medical management ( Meprate ) for a month, and then repeat the scan.
If the cyst persists or grows in size, consider Laparoscopy.
The line of management is absolutely okay.
Take care.
Above answer was peer-reviewed by
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