Pneumoperitoneum seen on an X-ray or computed tomography (CT) image points to a diagnosis of ruptured viscus and immediate surgery is warranted. A case of tubo-ovarian abscess (TOA) presenting with pneumoperitoneum is unusual. Very few cases have been reported where the pneumoperitoneum is caused by an abscess involving the adnexa.
A 17-year-old woman presented to the emergency department with gradual onset of pain in the right lower quadrant of two days duration, with no other associated symptoms. She was sexually active and was on oral contraceptive pills.Physical examination demonstrated a soft abdomen with tenderness in the right iliac fossa. Urine examination showed urinary tract infection (UTI) with E. coli, sensitive to cephalexin, and she was discharged on oral cephalexin.
Three weeks later, she represented with worsening upper abdominal pain radiating to the back, with shoulder tip pain and associated vomiting. Examination revealed tenderness in the right upper and lower quadrants and involuntary guarding. Erect chest X-ray showed gas under the right hemidiaphragm, with elevation of the diaphragm suggestive of pneumoperitoneum . An urgent ultrasound (US) scan of the abdomen showed 120 ml of free fluid in the pelvis but no other pathology. An urgent CT scan of the abdomen showed a large amount of free intra-abdominal gas and moderate fluid in the pouch of Douglas.
On laparoscopy, there was purulent peritonitis but no faecal matter in the cavity and the bowel examination showed intact bowel, an unexpected finding of bilateral hydrosalpinges, and a dilated left fallopian tube forming a complex mass involving the left ovary; pus was seen draining through the tube. A drain was inserted after drainage and washout of the pus. Subsequently, the patient was treated with intravenous ceftriaxone, metronidazole and azithromycin. The pus from the abdominal cavity did not reveal any significant growth but a urine specimen was positive for Chlamydia through polymerase chain reaction (PCR). The patient was commenced on oral amoxycillin clavulanic acid and doxycycline, as per therapeutic guidelines for severe sexually acquired PID. She recovered well postoperatively and was discharged home on day seven, with follow-up in outpatient clinic.
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