Answers

This is a tricky one! The presenting complaint is suitably vague and very common in General Practice (and sometimes in Emergency too). Its very hard to tell the most likely diagnosis from the history.

All of the differentials listed are possible.
There are a few clues that might make you more suspicious in this one.
The fact that she has put on weight is somewhat unusual. If there was a serious cause like Inflammatory Bowel disease, or coeliac disease, or some other true dietary intolerance, she would be more likely to have lost weight. The same is true for any cancers.

It is also important to EXCLUDE the most serious diagnoses. And you want to make sure she doesn’t have an ovarian tumour.

In this case, the diagnosis is a large, benign ovarian cyst.
The weight she has gained is due purely to he mass of the cyst itself. Sometimes they can be very large (think: this size of a football) and can weight several kilograms. These tumours can cause GI symptoms due to the physical irritation of the bowels by such a large mass.

If this lady had not had an obvious mass, the most useful first investigation would likely be some blood tests – including full blood count, urea and electrolytes, liver function tests, inflammatory markers (for inflammatory bowel disease), serum tTG for coeliac disease, and probably bloods that would screen for fatigue – such as iron studies, thyroid function tests, B12 and vitamin D. You might also want to think about a stool sample for fecal occult blood.

IBS – irritable bowel syndrome – although common, is usually a diagnosis of exclusion, and more serious pathology should be sought and ruled out before diagnosing this as the cause.

When investigating a palpable abdominal mass, ultrasound is almost always the investigation of choice. Abdominal masses are usually caused by:
– Pelvic pathology (more common in women) e.g. ovarian cyst
– Liver mass / enlarged liver
– Splenic mass / enlarged spleen
Hernias
Constipation (Clinical diagnosis – imaging not usually required. May be seen on AXR or CT but not an indication for either)
– Abdominal aortic aneurysm (rarely causes a mass)

Bowel cancer rarely causes a palpable bowel mass – although if it metastasises to the liver it may cause a palpable liver.
Constipation can sometimes be palpated as a vague mass in the LIF or RIF.

CT scanning is best for differentiating abdominal pain (as opposed to abdominal masses) – particularly in the acute setting. It can detect many pathologies, but commonly seen are:
– Causes of peritonitis / bowel rupture
Diverticulitis
Pancreatitis
– Inflammatory Bowel Disease
– Bowel obstruction (may also be detected with AXR)
– Bowel cancer (in the less acute setting probably colonoscopy is best. In the acute setting it is often the secondary effect – such as obstruction or perforation that is the reason for the pain)
– AAA with or without rupture
– Gall bladder pathologies (although many are better seen on USS)
Appendicitis (may also be seen better on USS)

This lady doesn’t need to go urgently to hospital via A+E. Her condition has been stable for several weeks or months. Her observations are all within the normal range. She is not clinically acutely unwell. And she does not have uncontrollable pain. It is safe for her to go home and have work-up as an outpatient, providing there is suitable ‘safety-netting’.

The Real Case

This patient had her USS a few days after seeing the GP and had a large ovarian cyst. She was seen privately by a gynaecologist and had the mass removed within a week. It was over 25cm in diameter! On histopathology it was determined to be a simple cyst.
On follow up one month later her symptoms had completely resolved and she had gone back to going to the gym daily. She was very grateful for the prompt diagnosis and treatment.

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