15 yr girl c/o severe pain in lower abdomen since 2days. no other complaints M/H- regular cycles, average flow for 3days , no dysmenorrhea , LMP 5 days back , no bleeding at present , menarche at 13 yrs Appendisectomy done 2 yr back O/E - tenderness n guarding + over lower abdomen p/s n p/v not done with dis history pt was admitted 8 days back , received IV antibiotics n painkiller , presently pt does not have any complain , beta hcg , AFP are normal , CA 125- 325u/ml ct scan report is as following kindly opine for further manegment



15 year old. MH reg 3/30. post appendicectomy. report says uterus didelphys. left functional ovarian cyst. left puj obstruction. I couldn't understand 4.4 3.2 cms ?complex cyst/tubo ovarian abscess. treatment : * do a IVP to know the anatomy &function of kidneys. *As she is a young girl, you can't do HSG. CT /MRI may be helpful in delineating uterine anatomy /anomaly. * do routine blood and urine investigations. see for any UTI. No other active management necessary if patient is asymptomatic.

urine C/S - streptococcus susceptible to nitrofurantoin , n pt has received nitrofer

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Thank you Dr. Ila Jain madam for the tag. Its an interesting case. I would like to do the following 1) S. LDH levels and S. Inhibin levels as they will help rule out other gct and scsts. 2)i sometimes prefer getting an additional MRI done which helps to characterise the lesion better 3) at age of 15, I'm not sure How much I would rely on CA 125 as it can be raised due to many causes. (though malignancy can also be one of them. Hence a MRI will better characterise the lesion. T1,T2,and fatsat sequences) 4)At this age I would go more in favour of teratoma or a TO abscess rather than anything else 5) define the cause of rt. Puj obstruction. If its not calculi u have to keep OHVIRA syndrome in mind (triad of uterus didelphys, obstructed vagina (there is collection in horns of uterus) and ipsilateral renal anomaly). They usually present at this age with lower abdominal crampy pain. Last option if all above doesn't lead to a diagnosis would be to do a diagnostic lap and biopsy of the rt. Ovarian lesion

Generally with bilateral this kind of cyst common history amenorrhoea but here regular menstrual history. Also ca 125 raised in endometrioma,tuberculosis,TO mass or any infective condition PID. rule out all and sent CBC AND URINE CULTURE AND SENSITIVITY.repeate ca 125 after 10 days of antibiotics.rule out renal anomaly as it is very common with mullerian anomalies.with antibiotics and analgesic pain subside indicate cause more likely infective. Here due to appendicectomy and TO mass scopy becomes dangerous due to adhesions.take risk convent.laparotomy is better.

From the mri, it looks like OHVIRA. She will need a vaginal septotomy. Should be attempted by hysteroscopy using a 3mm office hysteroscope if possible, helps to maintain hymenal integrity. The pain will subside after drainage of the obstructed system. Secondly get a functional scan of the kidney done. If function is normal and as I remember CT did not show calculi, she should be planned for lap PUJ repair.

Its an interesting case. I think get a MRI done, CA 125 though is raised but I think we should not jump on to malignancy straight away. I think she should be planned for surgery.

looks like congenital uterine anomaly,can go ahead for diagnostic lap,after explaining the parents,otherwise reassure very interesting case,kindly give us follow up

what about her kidneys are they in normal position

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Ninad Katdare , what do you think?

do IVP to rule out anomalies in kidney n MRI

Non communicating rt horn of uterus,which may he having blind lower end.So evaluate under anaesthesia. Simple ovarean cysts ,that too that small may not be giving problem

since there is non communicating RT Fallopian tube n kidney abnormality mullwrian abnormality can b there

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