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Special Feature |

Image of the Month—Quiz Case FREE

Jeniann A. Yi, MD; Clay Cothren Burlew, MD; Carlton C. Barnett, MD; Ernest E. Moore, MD
[+] Author Affiliations

Author Affiliations: Department of Surgery, Denver Health Medical Center, University of Colorado, Denver.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2012;147(9):885. doi:10.1001/archsurg.2011.1283a.
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A 53-year-old woman had abdominal pain, nausea, vomiting, and obstipation for 4 days. Her medical history was significant for bipolar disorder, schizophrenia, total abdominal hysterectomy after a complicated birth, and right oophorectomy for a hemorrhagic cyst. She was being followed up by the gynecology service as an outpatient for a left adnexal mass and was on their elective operative schedule for resection for a presumed ovarian malignant neoplasm. On examination, she had abdominal distention and was tender to palpation in the left lower quadrant. Her laboratory analysis findings, including a complete blood cell count and metabolic panel, were normal aside from elevated levels of CA 19-9 (35 U/mL), carcinoembryonic antigen (58.3 ng/mL; to convert to micrograms per liter, multiply by 1.0), and cancer antigen 125 (62 U/mL; to convert to kilounits per liter, multiply by 1.0). A computed tomographic scan of the abdomen revealed a complex cystic and solid pelvic mass measuring 13 × 15 cm, diffuse retroperitoneal lymphadenopathy, and cecal distention with a pedunculated area of mural enhancement in the transverse colon measuring 2 cm but no obvious obstructing colonic mass (Figure 1 and Figure 2). The gastroenterology service was consulted and declined to perform colonoscopy owing to a presumed inability to prepare the bowel.

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Graphic Jump Location

Figure 1. Computed tomographic scan (sagittal view) revealing a complex pelvic mass and right colonic distention. F indicates feet; H, head; L, left, and R, right.

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Figure 2. Computed tomographic scan (coronal view) of the pedunculated colonic mass (arrow). A indicates anterior; L, left, P, posterior; and R, right.

The patient was taken to the operating room and found to have a left adnexal mass as well as an intraluminal mass in her transverse colon with significant associated mesenteric lymphadenopathy. Mass resection, left salpingo-oophorectomy, and an extended right hemicolectomy with lymphadenectomy were performed.

WHAT IS THE DIAGNOSIS?

A. Perforated large-bowel obstruction with pelvic abscess

B. Primary colorectal carcinoma with ovarian metastasis

C. Synchronous colorectal and ovarian carcinoma

D. Ovarian carcinoma with direct mechanical colonic obstruction

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomographic scan (sagittal view) revealing a complex pelvic mass and right colonic distention. F indicates feet; H, head; L, left, and R, right.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Computed tomographic scan (coronal view) of the pedunculated colonic mass (arrow). A indicates anterior; L, left, P, posterior; and R, right.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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