CASE 10812 Published on 03.04.2013

Haemoperitoneum from bleeding corpus luteum cyst

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, M.D.; Villa Chiara, M.D.

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74 20157 Milan, Italy;
Email:mtonolini@sirm.org
Patient

24 years, female

Categories
Area of Interest Genital / Reproductive system female ; Imaging Technique CT
Clinical History
Sudden abdominal pain in a young, non-pregnant woman with unremarkable past medical history. Found tachycardic, with severe tenderness on the lower quadrants at physical examination, and suspected peritonitis. Gynaecological consultation excludes acute abnormalities of the external genital structures.
Urgent laboratory tests disclose severe blood loss (7.1 g/dL haemoglobin), mild leukocytosis.
Imaging Findings
Transvaginal ultrasound (not shown) performed by the attending gynaecologist disclosed abundant echoic effusion in the peritoneal cul-de-sac, to be investigated with urgent multidetector CT (Fig. 1).
Unenhanced images showed diffuse peritoneal fluid, with progressively increasing attenuation values from the upper abdomen, to the parietocolic gutters, clearly hyperdense (60-65 Hounsfield Units, HU) in the Douglas’ recess, consistent with haemoperitoneum.
In the pelvis, strongly hyperattenuating "sentinel clot" was identified abutting a 3-cm fluid-like right adnexal lesion with minimally thickened, enhancing wall, from which cloud-like contrast extravasation indicating active bleeding originated. No significant abnormalities were appreciated in the upper abdominal organs and uterus.
The patient’s clinical conditions rapidly worsened with hypotension, leading to blood transfusions and emergency laparotomic surgery. Massive haemoperitoneum from bleeding corpus luteum was confirmed, and treated with haemostasis and right ovarian cyst enucleation. Postoperativelym the patient recovered successfully.
Discussion
Acute pelvic pain in women is a relatively common cause of emergency department admission. Although ultrasound remains the primary modality of choice to assess suspected gynaecologic disorders, multidetector CT (MDCT) is largely requested in patients with abdominal and pelvic pain. Since MDCT is the fastest, readily available imaging modality, initial evaluation by MDCT is increasing, particularly when clinical diagnosis favours non-gynaecologic disorders such as appendicitis or diverticulitis, with equivocal ultrasound abnormalities or with extension extend beyond the sonographic field of view [1-4].
Bleeding into follicular or corpus luteum cyst represents a common cause of abrupt-onset lower abdominal pain in premenopausal women, and may lead to an emergent presentation. Laboratory shows anaemia, mildly raised inflammatory markers compared to other conditions such as appendicitis. Correlation with clinical history and serum βhCG levels is necessary to differentiate ruptured ectopic pregnancy, which may have similar manifestations. The increased vascularity in the luteal phase may predispose to cyst rupture, resulting in life-threatening haemoperitoneum with increasing, diffuse abdominal pain and hypotension [1, 2].
Considerable overlap exists between haemorrhagic follicular and corpus luteum cysts, and their differentiation primarily depends of clinical history, correlation with menstrual cycle and βhCG. The usual MDCT appearance is a 2-5 cm well-marginated unilocular adnexal lesion, with mixed unenhanced appearance due to a high-attenuation component (45–100 Hounsfield Units, HU), sometimes with fluid-fluid “haematocrit” level. Due to peripheral vascularisation, corpus luteum cysts display mildly thickened (<3mm) enhancing walls after intravenous contrast [1-5].
As this case exemplifies, the imaging hallmark of cyst rupture includes discontinuity of cyst wall, more hyperattenuating “sentinel clot” nearest to the bleeding site, active contrast medium extravasation suggesting ongoing bleeding, and haemoperitoneum. The hyperdense peritoneal effusion typically shows the highest attenuation values within the pelvis compared with the abdomen. Original cyst identification and distinguishing adnexal lesions from other structures such as omentum is often challenging. Whereas haemorrhagic ovarian cysts may be successfully managed conservatively, haemoperitoneum dictates urgent surgical intervention [1-6].
Besides ectopic pregnancy, panoramic exploration by MDCT is helpful in differentiation from other causes of spontaneous haemoperitoneum in reproductive age women [2, 6].
In conclusion, because of the increasing availability and use of this modality, familiarity with MDCT appearances of gynaecologic diseases that may be encountered regardless of study indication is crucial for prompt diagnosis and appropriate management. Multiplanar reformations help clarify pelvic female tract structures. Despite non-invasiveness and superior contrast resolution, use of MRI is usually hampered by limited availability and critical conditions [1-5].
Differential Diagnosis List
Ruptured corpus luteum cyst with haemoperitoneum.
Closed trauma
Ovarian follicular cyst
Ovarian torsion
Ruptured cystic teratoma or dermoid
Ruptured endometrioma
Pyosalpinx / Tubo-ovarian abscess in pelvic inflammatory disease
Pelvic haematoma
Ruptured ectopic pregnancy
Ruptured hepatic adenoma
Final Diagnosis
Ruptured corpus luteum cyst with haemoperitoneum.
Case information
URL: https://www.eurorad.org/case/10812
DOI: 10.1594/EURORAD/CASE.10812
ISSN: 1563-4086