Ruptured Ovarian Cyst

You are the general surgery CT1 asked to see a 16-year old girl with sudden onset right iliac fossa pain. How would you proceed. 

Example answer introduction

In this scenario I would be most worried about appendicitis although my differentials will include ruptured ovarian cyst, mesenteric adenitis, ureteric stone and urinary tract infection. I would assess this patient using an A-E approach, take a focused history and perform an abdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions. 

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, Trop I, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications 

  • Past medical history – inflammatory bowel disease, previous abdominal surgery, gynaecological history including LMP

  • Last meal

  • Events leading up to this point - nature of pain, nausea and vomiting, altered bowel habit, weight loss, PR/PV bleeding

  • Sexual history

Abdominal examination

  • Inspect – Distention, surgical/traumatic scars, hernia, Cullen’s sign

  • Auscultate – bowel sounds

  • Palpate – Tenderness, guarding, rebound tenderness, Rovsing’s sign

  • Percussion – Normal or hyper-resonant

  • Digital rectal and pelvic examination –Anal tags, fissures, blood, mucus

Example questions to progress the station

Q1 The pain started suddenly after sexual intercourse. In the past she has had mid-cyclical pain but nothing like this. She is haemodynamically stable. On examination she is very tender in the right iliac fossa but not guarding and there is no peritonism. The bloods you have sent off come back normal. What would you do next?

 

I would score her on the ALVARADO score. Normal laboratory investigations do not rule out appendicitis, but I would now be thinking more of a gynaecological cause. I would then request further investigations – 

 

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones, pregnancy test

  • Add on blood Beta HCG

  • Ultrasound abdomen and pelvis

 

Q2 Ultrasound shows a ruptured ovarian cyst. What would you do next?

Example answer. I would inform the general surgical registrar of my management of the patient and investigation results and then refer the gynaecology team for inpatient assessment. 

Initial management

  • IV crystalloids and catheter to maintain urine output of 0.5ml/kg/hr   

  • Analgesia according to WHO ladder

  • Keep nil by mouth

  • Inform general surgery and gynaecology registrars

  • Keep patient and any relatives informed

  • Document, document, document!!!

Key Points:

This scenario highlights the need to keep a wide differential. You will often meet this scenario in your training where the gynaecology team will not accept the patient unless appendicitis has been ruled out, so you will be called to work up the patient. Ruptured ovarian cysts are generally managed conservative unless there is heavy or ongoing bleeding. The gynaecology team will take over care and decide on further management. Your role in this scenario is to ensure the patient is ready for theatre if required. 

Useful Resources

Diagnosis and management of ovarian cyst accidents.

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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