Case Conference August 24th 2011

24-Aug-2011, Divisi ginekologi onkologi RSCM

Mrs. AN/ 43 yo/ P3/  GAKIN

 

HISTORY

 

On July 11^th 2011, patient came referred from “M” hospital with chief complain abdominal enlargement since sixteen months before, had been sought for medical attention at RSU Bogor. She was suspected to have an ovarian mass and then she was referred to RSCM. No complain about bloating. No complain in defecation or micturition.

In RSCM, Patient was examined in Gynecology Clinic and then consult to Oncology Division with cystic ovarian neoplasm with solid part suspected malignant.

 

Patient married 1 x, P3 (youngest child 14 yo)

Housewife

 

PHYSICAL EXAMINATION on admission

General status : compos mentis

BP 110/70 mmHg, HR 76x/minutes, RR 20 x/minutes,  temp 36,8˚C

Height is 154 cm, weight is 45 kg

Conjunctiva not anemic

No enlargement of supraclavicular/axilla/inguinal limph nodes

Heart/Lung : wnl

Abdomen: Cystic mass till xiphoid processus, limited mobility, abdominal pain (-)

Extremities were warm

 

Gynecologic status : On admission

Inspection       : no vaginal bleeding

Inspeculo         : porsio seemed normal, pushed to posterior

VRE                : uterus normal size and shape, appeared to be pushed to posterior by

mass. Cystic mass filling abdominal cavity till xiphoid processus, no mass       in the rectum.

 

Fetomaternal ultrasound

Cystic ovarian neoplasm with lipid balls appearance from teratoma suspected mature dd/ immature

 

CT Scan

Cystic mass with solid part from right adnexa, suggestive for ovarian malignancy, ascites and right pleural effusion

 

CA 125 145.9 U/ml

 

 

On 01/08/11

Laparotomy was performed (doctor in charge: dr.Hariyono W Obgyn (C) )

On exploration :

No ascites. Huge cystic mass filling whole abdomen till xiphoid processus, more than 30 cm, adhered with peritoneal wall till liver. Many fibrins attached. Did adhesiolysis.

FS result : teratoma with malignant transformation (squamous cell carcinoma)

Optimal debulking was performed à Total hysterectomy, bilateral salphingo-oophorectomy, total omentectomy, biopsy of peritoneum wall

Bleeding during operation was 1500 cc

 

Patient was taken care for 3 days in the ICU.

Giving antibiotic : ceftriaxon n doxyciclin

 

On 4^th day, patient got nauseas and vomit, greenish fluid, NGT inserted developed productive, greenish fluid.

 

Bowel movement was minimal. Abdomen was distended. Assess as paralitic ileus. TPN was given.

Three position whole abdomen X-ray:

BNO 05/08/11 : air distribution doesn’t reach minor pelvis, air appearance on right upper quadrant, above liver with wavy contour, no dilatation or thickening of intestinal wall, Air fluid level visible on LLD or semi-erect position à loculated ascites, suspect chilaiditi syndrome, no signs of ileus

Consult to digestive surgery à did conservative management, do chest x-ray

Chest X-ray 06/08/11 : left paracardial infiltrate, suspect minimal pleural effusion dd/pleuritis, no appearance of intraperitoneal free air

After 2 days, ileus was getting better, and the patient was start to get enteral feeding.

 

Patient care in the ward, regular diet 1800 kcal, protein 90-100 g/day

Preoperative albumin 3.47 à decreased to 1.28 g/dL (03/08/11)

Antibiotic was ceftriaxon and clavamox injection.

 

At 11/08/11, patient complaint vomit and distended abdomen, decreasing bowel movement and she was diagnosed as suspected paralytic ileus, treated conservatively with liquid diet, domperidon and omeprazole.

 

On 14/08/11 à patient felt dyspneic, abdomen distended, bowel sound (+), start again with enteral feeding.

 

Did chest x-ray 14/08/11 both hemidiafraghm highly located, intestine appeared to be dilated with step ladder appearance, suspected free fluid intraperitoneally

 

On 15/08/11, did BNO: intestinal air distribution doesn’t reach distal, air appearance inside intestine and stomach, extraluminer air appearance. Half sitting appearance and left lateral decubitus, abdominal opacity makes a very long air fluid level à pneumoperitoneum, ascites

 

On 15/08/11, did puncture of ascites came out reddish fluid, did culture, taken for analysis.

Isolat result was Klebsiella Pneumonia and pseudomonas Sp.

Both sensitive to meropenem and imipenem.

Pseudomonas sensitive to amikacin and ciprofloxacin.

Blood culture result: negative

 

On 16/08/11, physical examination by dr.Gatot Obgyn (C )

Localized air trapping, did puncture à came out air, after that fluid +/- 750 cc. , patient given metronidazole and ciprofloxacin and norit test.

 

On 17/08/11, norit test (+), came out feces like fluid +/- 1500 cc.

 

On 22/08/11, fluid production +/- 2300 cc/24 hour, assessed by digestive surgeon as high output fistula.

Clinically patient started to develop abdominal tenderness (+), muscular defence (+) à generalized peritonitis due to GI tract perforation,  severe hypoalbuminemia (alb 1,75)

 

On 22/08/11, did insertion of celsite in operating theatre.

 

 

PA operation specimen: Histology correspond to teratoma with malignant component malignant lymphoma and squamous cell carcinoma.no abnormalities in ectocervix or myometrium, no tumor spread in omentum

 

August 23th, 2011

General status :

Moderate illness, Compos Mentis

BP 100/60 HR 98 x/m RR 24 x/m  T : 38C

Abdomen tendernes (+), muscular defense (-)

No sign of cellulitis

Wound dehisense (+)

Lab result :

Albumin 1,75

PT/aPTT 1.1x/ 1x, Fib 387, D-Dimer 1200,  SGOT/SGPT 61/ 21

Ur/ Cr 27/ 0.4, Na/K/Cl 134/ 3,72/ 102.5

Hb 9.9 , Ht 30.5/ Leukocyte 11.850, Trombocyte 316000

 

Assessment :

Day 23 post laparotomy optimal debulking due to ovarian cancer advanced stage

Perforation of GI tract

Wound dehisense

Hipoalbuminemia

Nosocomial infection that sensitive only with imipenem and meropenem

Anemia

Impending sepsis

 

Management :

Conservative management or

Active management