Case Report Disseminated Granulomatous disease of peritoneal cavity presenting as carcinomatosis Rule of diagnostic laparoscopy

prepared by Dr: Mohammed El-Ron Head of surgery department Dr: Mohammed Olwan General surgery Resident (R4) Dr: Hasan El-Haj General surgery Resident (R3) Presented by: Dr: Hasan El-Haj

History 38 yr old female pt married, has 4 offspring's lives in Gaza Pt C/O of Abdominal pain since one months The condition started with mild diffuse abd pain associated with anorexia, vomiting and loss of weight and fatigue that worsened last week before presentation. Pt has no past medical illness nor surgical Hx No drug Hx No previous blood transfusion No significant family Hx

Examination General examination Chest and heart Abdominal Pt looks ill , in pain, pale vital sign stable afebrile ,, no jaundice no regional LN palpable Normal examination No abnormality detected The abdomen mildly distended with generalized abdominal tenderness mainly lower abdomen Bowl sounds decreased Shifting dullness with percussion

Lab Investigation Tumour marker CBC Chemistry WBC 14.5 Hb 10.4 Hct 45 Plt 220 Chemistry RBG 95 Urea 30 Creatinine 0.9 AST 35 ALT 55 LDH 980 Na+ 134 K+ 3.7 Ca++ 8.2 CRP 15 mg/dl Tumour marker CA 125 : 23.576 U/mL CEA : 109 U/mL

Radiological finding No abnormal detected U/S abdomen Chest X-Ray No abnormal detected U/S abdomen Diffused bowl distention with bowl wall edema Bilateral overian cyst Moderate amount of turbid fluid at pelvis

CT with Double contrast revealed intra-abdominal free fluid moderate amount diffuse peritoneal infiltrative lesions (with 3.5 cm thickness), which is considered as “omental cake bilateral ill-defined ovarian cystic lesion lesion of 9.8x7.0x5.5 cm was detected Edematous bowl wall mainly small bowl

CT

Provisional diagnosis and plan Signs and symptoms with radiological finding consistent with case of intra abdominal carcinomatosis with malignant ascites. highly suspicion of ovarian source The clarity of the diagnosis. Decision was made to do diagnostic laparoscopic exploration Consent was taken with anesthesia consultation and pt was prepared for surgery The pt sent for theater

Operative finding Diffuse disseminated carcinomatosis infiltrating the whole organs with edematous omentum ( omental cake ) Bilateral cystic lesion with irregular wall Moderate amount of turbid greenish fluid mainly at pelvis Biopsy was taken from omentum and the overian cyst wall Aspiration of the ascites for cytology

Histopathology Cytology : Pathology: non specific granulomatous disease No sign of malignancy Cytology : fluid cytology revealed frequent lymphocytes and the presence of reactive Inflammatory cells

Treatment and Prognosis Ciprofloxacin 400 mg IV /12 Hr Metronidazole 500 mg / Hr Prednisone 20mg / 24h Paracetamole 1gm S.O.S Pt start to improve and discharged home after one week F/U at outpatient clinic after 3 week showed full Recovery of the patient

Discussion Signs and symptoms associated with advanced ovarian carcinoma are abdominal distension, weight loss, ascites and pelvic or adnexal masses. Dx of Peritoneal carcinomatosis versus Granulomatous disease of peritoneum a rare diagnostic dilemma in ovarian masses. Many of these patients have radical surgery due to the difficulty of definitive preoperative diagnosis Disseminated Granulomatous disease mistaken for ovarian carcinomatosis based on an clinical findings CT findings and elevated CA-125. Disseminated Granulomatous disease can have the same clinical findings and it is in most cases diagnosed incidentally.

Rule of Diagnostic Laparoscopy We managed to avoid the Pt a destructive surgery by Diagnostic Laparoscopy With laparoscopy providing tissue diagnosis, and helping to achieve the final diagnosis without any significant complication and less operative time Diagnostic laparoscopy, when performed by general surgeons has an additional advantage of providing a definite treatment at the same time

Conclusion Many women with this disease are initially thought to have ovarian cancer and undergo unnecessary radical surgery because peritoneal granulomatous disease is not a diagnosis that surgeons consider, especially in cases without a high clinical suspicion. The majority of the cases are diagnosed intraoperatively. And established by histopathology So maintaining a high index of suspicion is very important for the successful treatment of peritoneal granulomatous disease Laparoscopy has proved to be an important tool in the minimally invasive exploration of selected patients, whose diagnosis remains uncertain