CASE 11135 Published on 09.09.2013

Giant uterine leiomyomatosis causing small bowel obstruction


Genital (female) imaging

Case Type

Clinical Cases


Tonolini Massimo, MD.

"Luigi Sacco" University Hospital,Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy;

46 years, female

Area of Interest Small bowel, Genital / Reproductive system female ; Imaging Technique CT
Clinical History
Perimenopausal woman with unremarkable past medical history and no previous surgery, presents to emergency department with lower abdominal pain, nausea and inability to pass stools since a week.
Physical examination reveals distended, diffusely tender abdomen with peristalsis, absent peritonism, and suspected pelvic mass. Laboratory discloses microcytic anaemia (8.2 mg/dl haemoglobin).
Imaging Findings
Initially radiographs (Fig.1) showed distended stomach and jejunal loops with air-fluid levels (consistent with clinical diagnosis of mechanical small bowel obstruction), outwardly displaced by a large demarcated right paramedian soft-tissue opacity.
Urgent multidetector CT (Fig.2) confirmed distended duodenum and jejunum with endoluminal fluid, and detected minimal peritoneal effusion. A huge, multilobulated heterogeneously-enhancing soft tissue mass occupied most of the pelvis and right hemiabdomen, containing some speckled calcifications. Multiplanar reformations (Fig.3) showed the mass protruding upwards from the uterus, indicating its origin from the reproductive tract. Small bowel obstruction apparently resulted from extrinsic compression by the mass at two sites.
Laparotomic surgery included total hysterectomy plus bilateral oophorectomy. Surgical exploration did not detect abnormal intestinal lesions. Cytology on peritoneal lavage yielded negative result.
She was discharged after an uneventful postoperative course. Anemia was attributed to chronic blood loss. Pathology of surgical specimen confirmed giant uterine leiomyomatosis without malignant changes.
Commonly known as fibroids, uterine leiomyomas (ULs) are benign proliferations that originate from the myometrial smooth muscle. By far the commonest pelvic tumour in women, ULs are present in more than 20% of women over 30 years of age. Hormone-dependent, ULs are typically encountered during the reproductive age, most frequent in overweight females, may enlarge during pregnancy or oral contraceptive use, and tend to shrink after menopause. Whereas the majority is asymptomatic, ULs can grow to large sizes, sometimes causing palpable masses, heavy menstruation, painful sexual intercourse, or urinary symptoms from bladder compression. Surgical treatment is indicated in cases of bleeding, rapid growth, pelvic pain or pressure symptoms [1, 2].
Pathologically, UL are usually circumscribed, unencapsulated masses, variable-sized and commonly multiple. They represent the commonest cause of uterine enlargement outside pregnancy, and may be either submucosal, intramural, or subserosal. Sudden growth or sarcomatous degeneration (incidence <0.8% of cases) are exceptional [2, 3].
To assess the female reproductive tract, ultrasound is the preferred first-line imaging modality. MRI is increasingly used as a problem-solving tool, particularly for mass characterization, tumour staging and follow-up. Nevertheless, despite ionizing radiation exposure and intravenous contrast use, CT is increasingly performed to investigate acute abdominal and pelvic pain of unknown origin, particularly in emergency settings (when a gynaecologic disorder is not initially suspected, or abnormalities extend beyond the pelvic ultrasound field-of-view) [3-6].
AT CT, uterine leiomyomatosis appears as an enlarged uterus with abnormal, lobulated contours, undetectable endometrial cavity, and presence of solid focal masses with attenuation values similar to those of uninvolved uterus. Variable in location from exophytic or subserosal to intramural to submucosal, ULs show highly variable enhancement, and may thus appear isodense, hypodense, or hyperdense after contrast. Strong hypodensity may result from hyaline degeneration and liquefactive necrosis. Present in only 4% of cases, coarse calcifications are quite specific for UL [2, 3, 5, 6].
Rather rare, giant leiomyomatosis may represent a diagnostic challenge, and requires special surgical considerations. As this case exemplifies, large multilobulated masses with heterogeneous attenuation that protrude from the uterus are compatible with leiomyomatosis, although not diagnostic. Differentiation from malignancies is usually limited, although multiplanar CT reformations help in determining the mass’ uterine origin. Besides increased abdominal girth, leiomyomatosis may cause hydronephrosis, thrombosis from venous compression, and occasionally bowel obstruction. Among the rarest complications associated with leiomyomatosis, the latter results from extrinsic compression by the enlarged uterus and/or adhesions, similarly to pregnancy-related occurrences [1,2,7].
Differential Diagnosis List
Small bowel obstruction from giant uterine leiomyomatosis
Uterine sarcoma
Endometrial carcinoma
Ovarian carcinoma
Metastases (Krukemberg’s tumour)
Pelvic inflammatory disease
Final Diagnosis
Small bowel obstruction from giant uterine leiomyomatosis
Case information
DOI: 10.1594/EURORAD/CASE.11135
ISSN: 1563-4086