Case Report

Nepal Med Coll J 2012; 14(3): 265-266

Ovarian cyst mimicking ascites on abdominal ultrasonography in a

prepubertal female
R Pathak1 and DB Karki2
1

Department of Obstetrics and Gynecology and 2Department of Radiology, Nepal Medical College Teaching Hospital,
Jorpati, Kathmandu, Nepal
Corresponding author: Dr. Ranjan Pathak, Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal;
Phone: 9779841498309 (mobile), e-mail: ranjanrp@gmail.com

ABSTRACT
Ultrasonography has been commonly used in the diagnosis of intraabdominal cysts like ovarian cysts. Massive
ovarian cysts can mimic ascites clinically (a condition termed pseudoascites) and ultrasonographically and can
cause delay in the diagnosis and management. Clinicians should therefore consider other differential diagnoses
in cases of large intraabdominal uid collection. We report such a case in a prepubertal female which was
diagnosed as ascites by ultrasonography initially but later turned out to be an ovarian cyst.
Keywords: Ovarian cyst, ascites, pseudoascites, ultrasonography.
Ultrasonography is commonly used in the diagnosis of
ovarian cysts. However, enormous ovarian cysts can
mimic ascites clinically and ultrasonographically.1,2
We describe a young girl with accumulation of uid
originally diagnosed as ascites by ultrasonographic
examination which ultimately proved to be an
ovarian cyst.

CASE PRESENTATION
A 13 year old girl presented to NMCTH medical
outpatient department with distension of abdomen
of two months duration. The patient complained of
gradually increasing abdominal distension (pants
did not t anymore), shortness of breath even at rest,
poor appetite and weight loss. There was no history
of vomiting, fever, jaundice, swelling over the face
or limbs, or change in bowel habit. Her past history
was unremarkable and she had not attained menarche.
General physical examination revealed pallor but no
icterus, pedal edema or lymphadenopathy. Vitals were
stable. Abdominal examination showed generalized
distension of abdomen with dilated veins but no
tenderness. The liver and spleen were not palpable.
Percussion note was dull all over the abdomen with a
positive uid thrill. Rest of the systemic examination
was unremarkable. Laboratory evaluation revealed
Hb 10 gm/dl, total leukocytes count 7 400/cumm with
normal differential count. Platelet count, ESR, serum
urea, creatinine, albumin, amylase, bilirubin, AST,
ALT, sodium and potassium were within normal limits.
Urinalysis and Chest radiograph were also normal.
An abdominal ultrasonogram showed large amount of
free uid in abdomen with appearance of bowel loops
oating into the free uid (Fig. 1). As a result, the

ultrasonographic impression was made as gross ascites.

An abdominal tap revealed serous uid with normal
total and differential counts, amylase and ADA levels;
the cytology, culture, Gram stain and Ziehl-Neelsen
smear were negative. Patient was initially treated nonoperatively comprising of uid restriction and diuretics
(spironolactone) and oral iron supplementation for iron
deciency anemia. But the patient did not respond.
Later on plain and contrast enhanced abdominal CT
was performed which demonstrated a huge abdominopelvic cystic lesion (Fig. 2). It consists of solid
components, bowel like extensions and calcications
which indicated ovarian cyst instead of a large uid
collection only. On laparotomy a huge ovarian cyst
arising from the left ovary was identied containing
both solid and multiple cystic areas. Cyst wall was
smooth, with no adhesions and minimal ascitic uid.
Left salphingoopherectomy was done. The cyst was
histologically identied as struma ovarii with benign
cystic teratoma. Seen two months after discharge, the
patient was doing well.

265

Fig. 1. Ultrasonography showing uid collection and

bowel loop-like areas

Nepal Medical College Journal

Fig. 2. CT images of the cystic lesion

DISCUSSION
Abdominal distension, bulging anks, shifting dullness
and a palpable uid thrill usually denote the presence
of ascites which is an abnormal collection of free uid
within the peritoneal cavity.3 While this diagnosis
is correct in most cases, occasionally similar signs
are observed in patients without free uid in the
peritoneal cavity. In those cases the term pseudoascites
is used, indicating that although the physical ndings
are highly suggestive of ascites, no free uid is present
in the peritoneal cavity. Fiedorek et al and Brophy et al
have reviewed the various causes of pseudoascites of
which some are giant mesenteric cysts, giant omental
and giant ovarian cysts.4-6

Ultrasonography is commonly used as the rst step in

the evaluation of patients suspected of intra-abdominal
pathology. It is the investigation of choice for clinicians
because it is very useful, widely available and without the
risk of harmful radiation. However, clinicians should also
recognize the limitations of ultrasonography and should
consider conditions other than ascites in the differential
diagnosis of large intra-abdominal uid collection. And
they should use other diagnostic modalities like abdominal
CT or laparoscopy to nd out other differential diagnoses
as well as to explore the cause of ascites.
REFERENCES
1. Menahem S, Shvartzman P. Giant ovarian cyst mimicking
ascites. J Fam Pract 1994; 39: 479-81.

Massive ovarian cysts ll the entire abdomen and can be

easily mistaken for ascites.7 Giant ovarian cysts mimicking
ascites have been reported previously but not in prepubertal
female. Our patient had no systemic disease known to
cause ascites. There were also no clinical or laboratory
ndings of local peritoneal disease such as tuberculosis.
She was evaluated in other hospitals and diagnosis of
ascites of unknown origin had been made. She had
undergone abdominal paracentesis as part of the laboratory
investigations. Unwitting ovarian cyst paracentesis yields
non-specic information on biochemical, microbiological
and cytological examinations.5 When in doubt about
the nature of such abdominal distension, abdominal
paracentesis should be avoided.8,9

2. Lombardo L, Babando GM. Giant ovarian cyst mimicking

ascites. Gastrointest Endosc 1986; 32: 245-6.

Considering the ultrasound of our case retrospectively,

echogenic areas were seen but they were assumed to be
bowel gas shadows instead of calcications. Similarly,
peristaltic waves in bowel loops like areas were not
assessed which is a common phenomenon in routine
scan. These two things could have altered the diagnosis
and therefore should be kept in mind while performing
the ultrasound of such large abdominal collections.

7. Bernal MS, Luna BI, Olivares CV et al. Giant cyst of

the ovary: Report of a case. Ginecol Obstet Mexico
2001; 69: 259-61.

3. Cattau EL, Benjamin SB, Knuff TE, Castell DO. The accuracy
of the physical examination in the diagnosis of suspected
ascites. J Amer Med Assoc 1982; 247: 1164-6.
4. Fiedorek SC, Casteel HB, Reddy G, Graham DY. The etiology
and clinical signicance of pseudoascites. J Gen Intern Med
1991; 6: 77-80.
5. Fiedorek SC, Gopalakrishna GS, Bloss RS. Giant omental
cysts presenting as pseudoascites in children. Tex Med
1986; 82: 42-5.
6. Brophy CM, Morris J, Sussman J, Modlin JM.
Pseudoascites secondary to an amylase-producing serous
ovarian cystadenoma. A case study. J Clin Gastroenterol
1989; 11: 703-6.

8. So CS, Schiedermayer D. Pseudoascites in the clinical

setting: avoiding unwarranted and futile paracenteses. Wis
Med J 2000; 99: 32-4.
9. Bar-Maor JA, Lernau OZ. Giant abdominal cysts simulating
ascites. Amer J Gastroenterol 1981; 75: 55-6.

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Vol. 14

September 2012

Regd. No. 88/054-55

1.

Trans-septal suturing following septoplasty: an alternative for nasal packing

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Study on carrier rate of Streptococcus pyogenes among the school children and antimicrobial susceptibility
pattern of isolates

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Patients satisfaction with eye care services at Nepal Medical College

A Ghimire, TR Limbu and R Bhandari

VOL. 14
NO. 3
September 2012

First Nepalese Journal indexed in Index Medicus/MEDLINE & PubMed

Nepal Medical College Journal

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Medical Education
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MD Bhattarai

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K Sen, A Adhikari, S Biswas, JC Chattopadhyay, U Pandey and U Pandey
263-264
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25. Ovarian cyst mimicking ascites on abdominal ultrasonography in a prepubertal female
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R Pathak and DB Karki
265-266
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CHIEF EDITOR: Dr. Sunil Shrestha, MBBS, MS
w.
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EDITORS: Dr. Tapas Pramanik, MSc, PhD, Dr. Reeta Marahatta, MS, Dr. Ritu Amatya, MD, & Dr. Kishore Singh Basnet, MD

Case Report

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