Presentation
Severe abdominal pain, nausea and vomiting, three weeks following uterine artery embolization.
Patient Data
The chest X-rays are unremarkable, with no free subdiaphragmatic intraperitoneal air.
There are multiple small, medium and large air-fluid levels within the small bowel suggesting partial but significant small bowel obstruction. There is eccentric right intrapelvic curvilinear gas. There is no free intraperitoneal air. Abdominal X-rays are otherwise normal.
The CT scanogram confirms a nasogastric tube (NGT) in situ and a urethral catheter. There is gastric distention and eccentric left hypochondrial small bowel distention. There is an eccentric rectosigmoid distention.
Multiphasic CT imaging confirms an enlarged, multi-fibroid uterus with intramural, submucosal, and subserosal fibroids. There is eccentric, focal, right-sided uterine fibroid calcification consistent with hyaline degeneration. Cystic uterine fibroid degeneration is also present. The bulk of the larger fibroids have intralesional gas, consistent with the history of a recent uterine artery embolization (UAE). There is a faint peripheral enhancement of some of the fibroids as expected.
Given the size of the patient, the noisy CT study, and the volume and flow rate of contrast injection, the level of uterine enhancement is still considered reduced and suggests early uterine necrosis following recent UAE.
Fluid filled and abnormally dilated stomach and small bowel, suggesting mid to distal small bowel obstruction. No free air. Gastro-esophageal reflux with a NGT in situ.
The pelvic bowel loops and ureters are displaced and drape around the enlarged and bulky, lobulated uterus. The bladder is also anteroinferiorly displaced and compressed.
No obvious extraluminal collection or abscess; however, this is difficult to exclude.
Image courtesy: Dr Amaresh I Ranchod.
Case Discussion
The patient presented three weeks following uterine artery embolization (UAE), performed in an external facility. The inflammatory and septic markers were markedly elevated, with clinical features suggesting bowel obstruction.
There is a complex CT imaging appearance. The multiphasic CT imaging confirmed a partial but significant small bowel obstruction. In addition, there is a radiological suspicion of uterine necrosis following the UAE.
At the time of laparotomy, uterine necrosis and sepsis, pelvic sepsis, and small bowel perforation and necrosis were noted. This required a hysterectomy and bowel resection over multiple surgical procedures.
Uterine necrosis is a rare but life-threatening complication following UAE 1. An MRI of the pelvis would have confirmed the CT suspicion; however, the patient was too ill and unstable to tolerate this study.
In this instance, the exact etiology of the small bowel obstruction is uncertain.
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