Bowel endometriosis.

Bowel obstruction accounts for 20% of hospital admissions due to acute abdominal pain. We report a case of acute bowel obstruction in a 31-year-old woman with a history of endometriosis diagnosed on laparoscopy a year before this presentation. Her clinical and biochemical picture suggested peritonitis and CT revealed an irregular soft tissue mass compressing a dilated rectosigmoid. Pockets of intraperitoneal gas were also documented and presumed to be secondary to bowel perforation at the level of the mass. Exploratory laparotomy was performed and the affected bowel was resected. Histology revealed extensive stricturing and fibrosis secondary to intestinal endometriosis. General practitioners, gastroenterologists and general surgeons are likely to encounter endometriosis, need to be competent in its diagnosis and management and collaborate promptly with the gynaecologist. Endometriosis should be considered in the differential diagnosis of every woman of childbearing age who presents with any gastrointestinal or abdominal symptom.

Parasitic dermoid cyst managed laparoscopically in a 29-year-old woman: a case report.

INTRODUCTION: Dermoid cysts are one of the most frequently occurring ovarian cysts; parasitic dermoid cysts, however, are extremely rare. CASE PRESENTATION: We report a case of a 29-year-old Japanese woman with an incidental finding of an adnexal mass on bimanual examination. Sonographic imaging reported an 8 cm mass in the Pouch of Douglas. This was found to be a parasitic dermoid cyst and was removed at laparoscopy. CONCLUSION: We believe laparoscopy to be a safe and effective means of managing parasitic ovarian dermoid cysts.

Gestational trophoblastic disease: is intensive follow up essential in all women?

OBJECTIVE: To determine the timescale of the registration process for gestational trophoblastic disease and its impact on hCG level at registration and subsequent need for chemotherapy. DESIGN: A prospective observational study using a standardised protocol for registration, assessment and treatment for molar pregnancy. SETTING: A supra-regional tertiary referral centre for gestational trophoblastic disease. PARTICIPANTS: A total of 2046 consecutive women registered between January 1994 and December 1998 with a diagnosis of molar pregnancy. METHODS: Data at and after registration, collected prospectively on a computerised database, were statistically analysed (by multiple logistic regression and ANOVA). MAIN OUTCOME MEASURES: Relationship between length of time to and hCG value at registration; also the subsequent need for chemotherapy. RESULTS: A total of 2046 women with a diagnosis of molar pregnancy were registered in the study period. The mean time interval between first evacuation and registration at the referral centre was 47 days (median 37, range 0-594). One hundred and five out of 2046 (5.1%) women needed chemotherapy. Sixty-three precent of the women (1296 out of 2046) had a normal level of urinary hCG (less than 40 IU/24 hours) at the time of registration and only one (0.08%) needed chemotherapy. Binary logistic regression analysis showed a statistically significant relationship between time to registration, hCG value, histology, pretreatment risk score and decision to administer chemotherapy. CONCLUSION: Women with gestational trophoblastic disease who were registered late were significantly more likely to have normal levels of hCG and were less likely to need chemotherapy. A less intensive follow up may be justified in women with gestational trophoblastic disease who are registered with a normal hCG level.

Asymptomatic vasculitis of the uterine cervix in presence of cervical intraepithelial neoplasia grade III.

CASE REPORT: A 34-year-old woman was diagnosed to have a high-grade cervical intraepithelial neoplasia and was treated by large loop excision of the transformation zone. Histology of the excised cone confirmed the diagnosis but also showed evidence of vasculitis of medium-sized vessels of the cervix. The woman was referred to a physician to rule out underlying systemic disease. Extensive laboratory and clinical screening was negative. DISCUSSION: The clinical significance and management of asymptomatic isolated vasculitis of the uterine cervix are discussed.

Bilateral hematosalpinx in a case of ectopic pregnancy: a clinical dilemma.

A 31-year-old woman with a positive pregnancy test and a transvaginal ultrasound scan result that was suggestive of a right tubal ectopic pregnancy underwent a laparoscopy, which showed bilateral hematosalpinx. In the presence of active bleeding and deteriorating hemodynamic status of the patient, a minilaparotomy was performed that revealed a right-sided hematosalpinx and a left-sided ectopic gestation.

Measurement of Brn-3a levels in Pap smears provides a novel diagnostic marker for the detection of cervical neoplasia.

OBJECTIVES: We have previously demonstrated that Brn-3a cellular transcription factor activates transcription of the human papillomavirus (HPV) E6 and E7 oncogenes in human cervical cancer cells and that Brn-3a levels are dramatically elevated in biopsies from women with high-grade cervical neoplasia. The aim of this study was to establish the relationship between Brn-3a levels in Pap smears and the histological diagnoses. We also analysed whether Brn-3a levels can be used in combination with Pap smear to predict the presence of cervical intraepithelial lesion. METHODS: Two hundred thirty-eight women who were referred with abnormal Pap smear underwent a diagnostic colposcopy, repeat in-study Pap smear, colposcopically directed biopsy, and assessment of Brn-3a and HPV-16 E6 m-RNA levels. Data were analysed to assess the association between Brn-3a levels and the histological diagnosis. RESULTS: Brn-3a was readily measured in smears and showed a statistically significant correlation with the grade of cervical abnormality. Positive Brn-3a is associated with increased relative risk of higher-grade lesion. Moreover, measurement of Brn-3a levels in smears can be used to detect a significant proportion of cervical lesions that were missed by Pap smear. CONCLUSION: Measurement of Brn-3a levels in routinely taken Pap smears is a feasible technique that correlates with the severity of the epithelial abnormality and is a useful adjunct to cytology. Brn-3a appears to have great promise since it detects activation of oncogenic HPVs rather than simply detecting their presence, as is currently being done.

Triage by HPV-DNA testing: is it useful in women with persistent minor smear abnormalities?

BACKGROUND: This study was carried out to evaluate the efficacy of HPV-DNA (Human Papilloma Virus) testing as a triage strategy for persistent borderline and mild cytological abnormalities. METHODS: A prospective cross-sectional study involving 321 women registered between January and December 2001 with two smears showing borderline or mild dyskaryosis, taken 6 months apart. This study was undertaken in a colposcopy unit in a large district general hospital in central London. RESULTS: Three hundred and twenty-one women referred with persistent borderline and mild dyskaryosis were recruited in this study. HPV-DNA testing was positive in 194 women (60.4%). Histology of colposcopically directed biopsy showed CIN2/3 in 57 women (18%). Fifty-one of these 57 women were detected by HPV-DNA testing (sensitivity for high-grade disease 89.5%). Specificity for high-grade disease was 45.8%. Negative predictive value was 95.3%. Women with a positive HPV-DNA result had a 7.2 times higher risk of having a high-grade cervical cancer precursor lesion. CONCLUSION: Negative predictive value of HPV-DNA testing for high-grade cervical lesion is very high. Hence, it can be used as a triage strategy for persistent borderline changes and mild dyskaryosis.

Tubal migration: a rare complication of an intrauterine contraceptive device leading to formation of a hydrosalpinx.

This is a case report of a unilateral hydrosalpinx caused by tubal migration of a copper intrauterine contraceptive device. A 33-year-old woman underwent laparoscopic right salpingectomy for a hydrosalpinx. During the procedure, a copper intrauterine contraceptive device was found protruding from the distal end of the hydrosalpinx.

Role of hysterectomy in management of gestational trophoblastic disease.

OBJECTIVE: To evaluate incidence, indications, and outcome of hysterectomy in women presenting with gestational trophoblastic disease. METHODS: A prospective observational study using a standardized protocol for registration, assessment, and treatment of gestational trophoblastic disease. A total of 5976 consecutive new patients registered between January 1986 and December 2000 with a diagnosis of gestational trophoblastic disease. The setting was a supraregional tertiary referral center for gestational trophoblastic disease. RESULTS: Between January 1 1986 and December 31 2000, 5976 new patients with a diagnosis of gestational trophoblastic disease were registered at Weston Park Hospital, Sheffield. Of these patients, 301 required chemotherapy. Forty patients underwent hysterectomy. The average pretreatment risk score in women who had hysterectomy was 7.4. The mean time interval between diagnosis of molar disease and hysterectomy was 17 months. Indications for hysterectomy included uncontrollable vaginal or intraabdominal bleeding, localized chemo-resistant disease, and placental site trophoblastic tumor. In this group, 31 of 40 women had chemotherapy and 14 patients needed more than one regimen. These women were also more likely to have atypical histology (3 invasive moles, 6 placental site trophoblastic tumours, 13 choriocarcinomas, and 2 dimorphic tumours). There were 10 deaths in all registered patients with molar disease and 4 of these were in the hysterectomy group. CONCLUSION: Hysterectomy was performed in 1 in 150 northern UK women with gestational trophoblastic disease. Patients needing hysterectomy represent an increased-risk group as indicated by their high pretreatment risk scores, atypical histology, frequent use of salvage chemotherapy, and higher mortality.

Case-series report: management of post-menopausal bleeding in the presence of an intrauterine device.

Post-menopausal bleeding in the presence of prolonged use of an intrauterine device should be investigated with hysteroscopy and endometrial sampling to rule out endometrial pathology. Here, we present two cases of prolonged use of intrauterine contraceptive device (IUCD), both associated with endometrial pathology, to illustrate the importance of these investigations.