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

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. CT

9. 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

10. 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

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

15. 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

16. 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.

17. 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

18. 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