TORSION OF A LARGE OVARIAN CYST PRESENTED AS AN ACUTE ABDOMEN: CASE REPORT

ТОРЗИЈА НА ГОЛЕМА ЦИСТА НА ЈАЈНИК ПРЕЗЕНТИРАНА КАКО АКУТЕН АБДОМЕН: ПРИКАЗ НА СЛУЧАЈ Sasho Pucakoski1, Nadezda Spiroska2, Andrej Nikolovski3 1 General Hospital Prilep, Republic of North Macedonia 2 University Surgery Clinic „Ss. Naum Ohridski”; Skopje, Republic of North Macedonia 3 University Surgery Clinic „Ss. Naum Ohridski”; Ss Cyril and Methodius University in Skopje, Faculty of Medicine, Skopje, Republic of North Macedonia

The diagnosis in such cases is often challenging because often the initial CT report can confuse the surgeon whether the mass arises from the mesentery or the urogenital tract.

Introduction
According to the National Institute of Health research results, 5% to 10% of women in the United States will require surgical exploration for an ovarian cyst during their lifetime. Of those cysts 13% to 21% will be malignant 1 .
However the prevalence in postmenopausal women is 14% to 18%, with an yearly incidence of 8%. It was reported that 30% to 54% of postmenopausal ovarian cysts will persist for years 2,3 .
Most of the ovarian cysts are asymptomatic, with the cysts being discovered incidentally during ultrasonography or routine pelvic examination in the patients. Some cysts, however, may have a range of symptoms, which sometimes can be severe, such as: discomfort or pain in the lower abdomen due to local organ obstruction, severe pain from rupture or torsion (twisting) of the adnexa 4.

Case presentation
A 70 years old female patient presented in the emergency department with a severe diffuse abdominal pain which started earlier that day. She was previously diagnosed with atrial fibrillation, treated with oral anticoagulant therapy for 8 years. She underwent Caesarean section 40 years ago.
Physical examination revealed tenderness in the peri umbilical area and the lower abdomen.   In the postoperative period the intestinal function was reestablished.

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The patient was discharged on day 6 post operation. Seroma of the surgical wound occurred at first check up. It was treated in an outpatient setup. The pathology report described a cystically changed ovarium with massive oedema, congestion, extensive hemorrhage, and polymorphonuclear infiltration. Ovarian infarction, due to torsion (twisting) of the cyst occurred.
There was no presence of atypical or malignant cells reported in the Report.

Discussion
Large intra abdominal cystic lesions can present with certain diagnostic challenges and difficulty in the setting of straight diagnosis due to the image overlapping of different abdominal entities. In some cases the cystic lesion can be recognized to arise from a certain organ in the abdominal cavity. Therefore the diagnosis is more straightforward. Oc-casionally the presentation of these large cysts can mislead and cause diagnostic difficulties 5 .
Large abdominal masses can compress local organs, such as intestines and lead to obstruction and potential necrosis of these organs 6 . Therefore the need for urgent surgery in such masses sometimes is necessary in order to avoid irremediable changes of the intestines.
Female patients admitted to emergency department with symptoms of an acute abdomen, nausea and vomiting, should always be examined for intestinal pathologies as well 6 . In our case, the intestines and other surrounding organs were non-compromised.
Detorsion of a twisted ovarian cyst is preferable management in younger patients, in order to salvage ovarian function and preserve its fertility 7 .
Most of the cysts are benign, but there are a few that are malignant and they're presenting with a very low rate of survival. In such cases the diagnosis should be obtained surgically, while the biopsy and aspiration can often be harmful 8 . Age factor is important in terms of increased malignancy rate possibility. Median age for ovarian carcinoma was found to be 63 years 9 . Sharma et al. included 186 postmenopausal women who underwent a surgical evaluation for ovarian cyst 10 cm or larger. Malignant process was found in 13%, which indicates that the larger the cyst gets, the bigger the chance for it being malignant is 10 . Knowing these facts, the clinicians should try to balance the risk of surgery for what may be a benign mass and the risk of a delay of diagnosis in potential malignancy 8 .

Conclusion
A giant ovarian cyst is a rare condition and management is challenging, mainly because of the difficulty to set the correct diagnosis upfront.
Occasionally it can present as acute abdomen due to a cystic torsion (twisting). No matter the diagnostic challenges, surgery is the mainstay of its treatment in order to avoid compromise and gradual worsening of the patient's condition. Even more when the patient presents with an acute abdomen, surgery is indicated no matter the origin of the cyst lesion.