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      Generalized Peritonitis Secondary to Spontaneous Perforation of Pyometra in a 63-Year-Old Patient

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          Abstract

          Spontaneous perforation of pyometra resulting in generalized diffuse peritonitis is extremely uncommon. Herein, we report the case of a 63-year-old woman who presented to emergency department with a 2-day history of severe diffuse abdominal pain, high-grade fever, nausea, and vomiting. Acute abdomen series was done, and upright plain chest radiograph showed free air under diaphragm. A noncontrast-enhanced computed tomography scan showed a significantly distended fluid-filled uterus measuring 10 × 7.8 × 10 cm, in addition to a single focus of perforation involving the uterine fundus and associated with presence of free air within the nondependant area. No evidence of ascites or pelvi-abdominal lymphadenopathy was identified. A preoperative diagnosis of generalized peritonitis secondary to spontaneous perforation of uterus was established. Subsequently, patient underwent urgent exploratory laparotomy which revealed pus-filled uterus with perforated fundus. Diagnosis of generalized peritonitis secondary to spontaneous perforation of pyometra was established. Consequently, patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, as well as thorough drainage and irrigation of pelvi-abdominal cavity. Postoperatively, patient was admitted to intensive care unit. Histopathological examination of uterus was negative for malignancy, and surgical culture grew Streptococcus constellatus. Patient had an uneventful recovery. Moreover, a brief literature review on pyometra is presented.

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          Most cited references24

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          Pyometra. What is its clinical significance?

          To evaluate the clinical outcomes of pyometra. Retrospective study conducted between 1993 and 1999 in two regional hospitals. Pyometra represented 0.038% of gynecologic admissions. Of the 27 women with pyometra, 6 (22.2%) cases were associated with malignancy, 1 (3.7%) was associated with genital tract abnormality, and 20 (74.1%) were idiopathic. Patients with idiopathic pyometra tended to be older and had a higher incidence of concurrent medical conditions. Five (18.5%) women experienced spontaneous perforation of pyometra. A preoperative diagnosis was correctly made in 17 of 22 (77.3%) patients without spontaneous perforation. Most women were treated with dilatation of the cervix and drainage. Nine women (33.3%) had persistent or recurrent pyometra; three of them were asymptomatic. Pyometra is an uncommon condition, but the incidence of associated malignancy is considerable, and the risk of spontaneous perforation is higher than previously thought. Dilatation and drainage is the treatment of choice, and regular monitoring after initial treatment is warranted to detect persistent and recurrent disease.
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            Spontaneous Uterine Perforation due to Pyometra Presenting as Acute Abdomen

            Spontaneous perforation of the uterus is rare, its incidence being about 0.01% − 0.05%. We report a rare case of diffuse peritonitis caused by spontaneously perforated pyometra. A 63-year-old woman with severe abdominal pain was admitted to our hospital. Laparotomy was performed because of the suspicion of gastrointestinal perforation with generalized peritonitis. At laparotomy, about 900 mL of pus was found in the peritoneal cavity. There were no abnormal findings in the alimentary tract, liver, or gallbladder. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathological investigation of the surgical specimen revealed endometritis and myometritis of the uterus; but there was no evidence of malignancy, and the cervical canal was patent. Although spontaneously perforated pyometra is rare, a perforated pyometra should therefore also be considered when elderly women present with acute abdominal pain.
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              Clinical characteristics of perforated pyometra and impending perforation: specific issues in gynecological emergency.

              To evaluate the clinical characteristics of pyometra and the differences between perforated pyometra and early-drained pyometra in order to prevent morbidity. Retrospective study of 14 patients diagnosed between 1998 and 2008 with early-drainage pyometra and six patients with perforated pyometra were included. In addition, a review of the literature yielded another 30 perforated pyometra cases for comparison. Of 20 women with pyometra, the main presented symptoms at admission were abdominal pain (80%), fever (45%) and vaginal discharge (25%). The majority of organisms isolated were Bacteroides fragilis (seven cases), Streptococcus species (six cases) and Escherichia coli (five cases). Of the 36 cases with spontaneous uterine perforation to date, 35 cases (97%) had abdominal pain, 11 cases (31%) had fever, and 10 cases (27%) had vomiting. Hypoalbuminemia was found in seven patients (five cases in the perforation group and two cases in the drainage group). Early diagnosis of pyometra before perforation can avoid surgical exploration and decrease morbidity and mortality. Perforated pyometra should be considered as a differential diagnosis in women with pneumoperitoneum and fever. Hypoalbuminemia should be considered as a predisposing factor for pyometra perforation.
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                Author and article information

                Journal
                Case Rep Obstet Gynecol
                Case Rep Obstet Gynecol
                CRIM.OBGYN
                Case Reports in Obstetrics and Gynecology
                Hindawi Publishing Corporation
                2090-6684
                2090-6692
                2013
                29 August 2013
                : 2013
                : 929407
                Affiliations
                1College of Medicine, Alfaisal University, P.O. Box 50927, Riyadh 11533, Saudi Arabia
                2Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center (KFSH&RC), P.O. Box 3354, Riyadh 11211, Saudi Arabia
                3Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria 21526, Egypt
                Author notes

                Academic Editors: P. Kovacs, S. Rasmussen, and H. R. Tinneberg

                Article
                10.1155/2013/929407
                3773424
                24073347
                a9a2eb90-a50e-4ef4-a470-a647f8d7bee5
                Copyright © 2013 Ahmed Abu-Zaid et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 20 June 2013
                : 31 July 2013
                Categories
                Case Report

                Obstetrics & Gynecology
                Obstetrics & Gynecology

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