BILATERAL OVARIAN TERATOMAS WITH LEFT RUPTURE AND CHEMICAL PERITONITIS

1. Department of General Surgery, University Hospital Mohammed VI. 2. Department of Obstetrics and Gynecology, University Hospital Mohammed VI. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 25 November 2019 Final Accepted: 27 December 2019 Published: January 2020


Discussion:-
Chemical peritonitis and dermoid cysts are the consequences of intraperitoneal rupture of a mature cystic teratoma (or dermoid cyst) of the ovary. Rupture is the most common complication after torsion but it concerns only a small percentage of mature cystic teratomas [1]. These are the most common tumors of the ovary before the age of 45. The incidence is 8.9 cases/100000 women. They represent 20% of all ovarian tumors in adults and 50% of ovarian tumors in children. The involvement is bilateral in 8 to 15% of cases and they are predominantly right in unilateral cases with represents 72.2% of cases [2]. The dermoid cysts of the ovary generally comprise the mature derivatives of the 3 embryonic layers. The cutaneous tissue and its appendages are almost always present in teratomas, the only constituent (30% of case) or in variable quantity compared to the other tissues. The sqamous layer is generally nonkeratinizing and non-parakeratotic, and its stroma contains a variable number of hair follicles, sebaceous glands and sweat glands. Sometimes, the squamous layer can be hyperplastic [3]. In most cases, abdominal pain is the most frequent inaugural sign. It sometimes can be associated with non-specific signs such as constipation, nausea, loss of appetite, fever or dysuria. In less than 5% of cases, endocrine signs are indicative of an ovarian mass. It can either be of hyperestrogenism which are the most frequent or signs of hyperandrogenism revealing of a cyst or a heterogenous ovarian mass. Dermoid cysts are sometimes very large and can cause gynecological or digestives system symptoms due to the compression of the rectum. Nausea and vomiting should cause fear of torion or hemorrhage due to rupture of the mass, these signs may point to acute appendicitis [3,4]. Abdominal examination may reveal a sensitive abdominal mass, medial due to the abdominal position of the ovary.
Dermoid cysts can present themselves as surgical emergency due to acute abdominal pain [4]. In our case, the patient was admitted for acute appendicitis. Dermoid cysts can be revealed by their complicated forms:

Torsion:
The ovary or appendix turn on themselves and become twisted. The torsion manifests as severe, intense pelvic pain, sometimes associated with nausea and vomiting. The diagnosis is based on clinical examination and by Doppler ultrasound.

Rupture:
The rupture manifests itself by a brutal pelvic pain, of moderate intensity, sometimes associated with nausea or vomiting. The diagnosis is made by clinical examination and by ultrasound, showing a collapsed ovarian cyst associated with abundant peritoneal effusion. Acute chemical peritonitis: In the event of massive leakage of the cystic contents after spontaneous rupture, the clinical picture observed is acute. Spontaneous rupture can be favored by pregnancy or childbirth; the acute revealing picture may be preceded by a phase of intermittent pain. The CT scan images are those of a pelviperitonits with edema of the great omentum, thickening of the parietal and especially visceral peritoneum, and presence of inter-loop collections. It is the coexistence of the signs of pelviperitonitis with a matureuni or bilateral cystic ovarian teratoma which makes it possible to evoke the diagnosis and differentiate this 489 clinical picture from that observed in other etiological circumstances of acute pelvic inflammatory disease (acute appendicitis, sigmoiditis, adnexal infection).

Infection:
Coliform bacteria are the most frequent involved organisms. A recent study carried out in the United Stated by Ryan is the first of its kind concerning the infection of a dermoid cyst by staphylococcus aureus sensitive to methicillin leading to a differential disgnosis of appendicitis [6]. Obstructive complications: a large tumor of the ovary can cause compression on neighboring organs (bladder, rectum, colon, iliac vessels) and can therefore be associated with compressive complications (overactive bladder, dysuria, constipation, venous thrombosis [7,8,9]). Beyond the clinical examination, it is important even in a surgical emergency, to perform imaging: ultrasound is the examination of choice in the initial assessment. Magnetic resonance imaging (MRI) and computed tomography (CT) are performed as a second intention. In front of any ovarian mass, the dosage of tumor markers preoperatively (αFP and βHCG) is essential, to guide the etiological diagnosis and eliminate a possible malignant component. Theses markers do not have organ specificity. An increase in αFP within the framework of an ovarian mass confirms the highly malignant yolk contingent of the tumor whereas that of βHCG, may correspond to a choriocarcinomatous secretory component. Furthermore, there absence does not exclude malignancy (non-secreting malignant germ tumors) [10]. In case of abdominal massthe differential diagnosis is ectopic pregnancy and infectious diseases [11]: pyosalpinx, tubo-ovarian abscess, pelvic abscess (appendicular or Crohn's disease), peritoneal including cyst (after periotenal surgery or gynecological infection) and extra gonadal pelvic tumors. In case of acute abdominal pain, the differential diagnosis of ovarian torsion is acute appendicitis, especially in case the pain is localized in the right iliac fossa with tenderness on palpation, fever and leucocytosis. The treatment of benign ovarian tumors remains exclusively surgical since no medical treatment has proven its effectiveness. Taking into account the benign mature of ovarian cysts the surgical procedure must be as conservative as possible because we are treating young fertile women. [12]. Postoperative surveillance of tumors is justified as part of organic tumor with a risk of recurrence. In the context of organic tumors, surveillance is based on the recurrence of clinical signs, the elevation of specific tumor markers and ultrasound imaging.

Conclusion:-
Thanks to an early diagnosis and an adequate treatment mainly surgical, the prognosis of ovarian teratomas is excellent but requires prolonged surveillance.