CASE PRESENTATION ON KOCH'S ABDOMEN

1. CASE PRESENTATION ON
ATYPICAL CASE OF KOCH’S
ABDOMEN BY: DR ANJALI TRIPATHI GUIDE:
DR J. PANDA,
PROFESSOR AND HOD
DEPT. OF OBGYN
KIMS, BBSR

2. PATIENT PARTICULARS
 Name: Mrs X
 Age : 31 years
 Address : Puri, Odisha
 Religion : Hindu
 Occupation: Housewife
 Status: Middle socio economical status
 Date of admission: 06/05/23

3. CHIEF COMPLAINTS
◦Abdominal pain and abdominal swelling from 3
months.

4. HISTORY OF PRESENT ILLNESS
The patient was apparently alright 3 months back, when she
complained of abdominal pain and swelling.
The pain was generalized, dull aching, intermittent, not
associated with fever, vomiting and relived on taking medication
and was associated with abdominal swelling which was
progressively increasing in size and loss of appitite

5. Initially, she had consulted in SUM HOSPITAL 3 months back, where
she underwent general examination that revealed ascites .
Ca125 - 356.9 U/mL and she was provisionally diagnosed as a case
ca ovary.
CECT Abdomen - Reports revealed a large subserosal fibroid arising
from left lateral wall of fundus of size 14x11x12cm with gross
ascites.
Then, ascitic tapping was done but reports for aspiration cytology
was not available.
Later on, she consulted another doctor in AIIMS BBSR, when she
developed abdominal distension again. Ascitic tapping was done
there.

6. After 15 days, she complained of abdominal distension again.
She came to OBG OPD for consultation and MRI Abdomen and
Pelvis was advised that revealed a large heterogenous enhancing
lobulated mass lesion of size 152x110x128mm arising from the
fundus and posterior wall of uterus and extending superiorly
supraumblical region of abdomen and gross ascites, respectively.
She was then referred to Dept. of pulmonary medicine in KIMS and a
CXR and CECT THORAX was done the revealed that a left sided
pleural effusion and features suggestive of inflammatory pathology
likely koch’s along with visual ascites, respectively
Ascitic tapping and thoracocentasis was performed and fluid sent
for aspiration cytology.

7. MENSTRUAL HISTORY
 Menstrual cycles -3-4 days /28-30 days
-Regular cycles
-normal flow
-not associated with passage of clots
-not associated with dysmenorrhea
 LMP- 18/04/23

8. OBSTETRICS HISTORY
P1L1
Previous LSCS
LCB-10 years back
Child - doing well
PAST HISTORY
No history of any chronic illness
No history of any contact with TB infected patient
No History of any previous surgery except previous LSCS

9. FAMILY HISTORY
Father is a known case of type 2 diabetes mellitus
TREATMENT HISTORY
 She had undergone ascitic tap 3 times and thoracocentesis
once in the past

10. PERSONAL HISTORY
Regular bladder and bowels habits
Mixed diet
No known allergies
Normal sleep wake cycle
 No history of loss of weight but reduced appetite

11. GENERAL EXAMINATION
Body built : average
Nourishment : average
Height : 152 cm
Weight : 60 kgs
BMI : 26 kg/m2
No signs of pallor, icterus, edema ,cyanosis ,clubbing and
lymphadenopathy

12. VITALS
Temperature-97.6 F
B.P-100/70 mm of hg
Pulse -80/min
Respiratory rate – 20/min

13. SYSTEMIC EXAMINATION
 RS - Right side vesicular breath sound heard
Diminished breath sounds heard on left side
On Percussion: Dull note was present in left lung base
CVS - S1,S2 heard.
No murmurs or added sounds
 CNS - Higher mental functions intact

14. LOCAL EXAMINATION
Per Abdomen:
On Inspection:
− Abdomen was distended
− Umbilicus centrally placed and
everted
−Skin over the abdomen appears to
be healthy
− No visible pulsations present
−LSCS scar was healthy
On Palpation:
− A mass of about 18-22 weeks
size was palpated arising from
pelvis
− Freely mobile in all directions
− Non tender
− Firm to solid in consistency
− Smooth and regular borders
− Lower pole could not be
reached

15. On Percussion:
−Dull note was present over the
swelling, resonant over flanks
−Shifting dullness and fluid thrill present
 On Auscultation:
− No arterial bruit or venous hum heard

16. P/S- Cervix, Vagina appears healthy
P/V-Cervix taken up, abnormal mass felt, mobile
all fornices free .
P/R- Rectal mucosa free, no nodularity on pod

17. PROVISIONAL DIAGNOSIS
◦ Large Sub serosal Fibroid uterus with ascites with pleural
effusion

18. Recent investigations
20/03/23
CEA- 1.12 ng/ml
CA 125- 356.9 U/Ml ()
LDH-242 U/L()
AFP- 2.98 ng/ml
ß- HCG- <0.1 Miu/ml
Hb-13.1mg/dL
TLC-9.3
TPC- 150,000/mm3
02/05/23
 ESR- 34MM
 Gram Stain Fluid- Few polymorphs, no organism
 PLEURAL FLUID: PROTEIN- 4.91 gm/dL
GLUCOSE- 116mg/dL
LDH- 134 U/L
ADA LEVELS- 4.8IU/L
CYTOLOGY: No malignant cells
CBNAAT: NEGATIVE for tuberculosis
infection
04/05/23
 Ascitic fluid : PROTEIN- 4.69 ng/mL
GLUCOSE- 126 U/L
LDH- 115 U/L
ADA LEVELS- 4.3 IU/L
CYTOLOGY: No malignant cells
10/04/23
 LFT: SGOT- 15.4 U/L
SGPT- 10.5U/L
ALP- 33 U/L
GGT- 9 U/L
ALBUMIN- 4.09gm/dL

19. Contd.
 MANTOUX TEST was done that was
POSITIVE (16mm) for tuberculosis infection.

20. Chest Xray PA-View showing left
sided pleural effusion.

22. T2 Weighted image of MRI
Abdomen and Pelvis
Size: 152x110x128mm
T1 Weighted image of MRI
Abdomen and Pelvis

23. INTRA OPERATIVE AND POST
OPERATIVE PERIOD
She had undergone explorative laparotomy on 11/5/23.
Midline infra umbilical incision given and abdomen opened in layers. Ascites
was present and the fluid was drined out as well as sent for cytology
A large sub serosal myoma of size 15x9x8 cm was seen arising from left
posterolateral wall near the fundus. Vasopressin injected into myoma base and
myomectomy done. Base was sutured with baseball suture.
One abdominal drain and one subcuticular drain was given to monitor the
output
Skin closed with ethilon as mattress sutures.

25. CONTD.
 Post operative period was uneventful.
On post operative day 2, IGRA test was advised which came
out to be POSITIVE .
She was started on anti tuberculosis drugs as per NTEP
The patient was then discharged on POD-11 after suture
removal. The suture site was healthy at the time of discharge.
HPE report confirmed the finding of leiomyoma

26. PSEUDOMEIGS’
SYNDROME
ABDOMINAL
TUBERCULOSIS
MALIGNANT OVARIAN
MASS
History of abdominal
distension
+ +/- +
Dyspnea + + +/-
History of fever, weight
loss
- + +
On palpation: lower
border reached
- +/- +/-
Consistency Firm Doughy Cystic /solid
Tenderness - + +/-
On percussion: note Dull note but flanks are
resonant
Dull /resonant note Dull note in flanks and
over mass
On bimanual
examination
Mass may or may not
be continuous with the
cervix
NA Mass separated from
uterus

27. FINAL DIAGNOSIS
SUBSEROSAL LEIOMYOMA WITH ABDOMINAL TUBERCULOSIS

28. DISCUSSION

29. TUBERCULOSIS
TB DISEASE BURDEN IN INDIA: 193 cases / lakh
population
 Reported TB cases : 12.8 lakhs (So far-Aug’21)

30. CASE DEFINITIONS
Bacteriologically confirmed TB
 refers to a presumptive TB case from whom a biological specimen is positive for acid
fast bacilli, or positive for Mycobacterium tuberculosis on culture, or positive for
tuberculosis through Rapid Diagnostic molecular test
Clinically Diagnosed TB
refers to a presumptive TB case who is not microbiologically confirmed, but has been
diagnosed with active TB by a clinician on the basis of X-ray abnormalities,
histopathology or clinical signs with a decision to treat the patient with a full course of
Anti-TB treatment.
Presumptive TB :refers to a person with any of the symptoms and signs
suggestive of TB
−cough >2 weeks
−fever >2 weeks
−significant weight loss
−haemoptysis
−any abnormality in chest radiograph.

31. Classification based on history of previous TB
treatment
New TB patient
A TB patient who has never had treatment for TB or has taken anti-TB drugs
for less than one month is considered as a new TB patient.
Previously treated TB
A patient who has received one month or more of anti-TB
drugs in the past.
Recurrent TB patient - A TB Patient previously declared as
successfully treated (cured/treatment completed) and is subsequently
found to be microbiologically confirmed TB is a recurrent TB patient.

32. Treatment after failure patients - those who have previously been
treated for TB and whose treatment failed at the end of their most
recent course of treatment.
Treatment after lost to follow-up A TB patient previously treated
for TB for one month or more and was declared lost to follow-up
(LFU) in their most recent course of treatment and subsequently
found to be microbiologically confirmed TB

35. CASE REPORT

36. REFERENCES
Afzal H, Saleem B, Huma A. Low Back Pain: Not a Segmental Pathology. Biomed J Sci & Tech Res
1(5)- 2017. BJSTR.MS.ID.000471. DOI : 10.26717/BJSTR.2017.01.000471
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5025132/
Hawkins and bourne; Padubidri VG, Daftray SN; Shaw’s textbook of Gynaecology, 18th edition
https://www.cdc.gov/tb/publications/factsheets/testing/igra.htm

37. THANK YOU

40. PSEUDOMEIGS’ SYNDROME
◦ Triad of:
◦ Ascites
◦ Pleural Effusion
◦ Benign tumors of the ovary (other than fibromas)
Benign tumors in this category include mucinous cystadenomas, teratomas, struma ovarii, and
leiomyomas
INCIDENCE:

41. MEIGS’ SYNDROME
◦ Benign fibroma or a fibromalike tumour of the ovary (such as thecoma and granulosa
cell tumours)
• Ascites
• Pleural effusion(s)
• Removal of tumour must cure the patient
• INCIDENCE: About 1% of ovarian tumors can present as Meigs syndrome.

42. Pathophysiology
◦ The exact pathogenesis of the ascites is still unknown.
◦ A possible theory is that there is filtration of interstitial liquid into the peritoneum through the
ovarian tumour capsule.
◦ This then moves from the peritoneal cavity to the pleural cavity through diaphragmatic defects or
via the lymphatic channels and eventually causes an exudative pleural effusion.
◦ An imbalance between the blood supply to a large tumour and its venous and lymphatic drainage
may be responsible for stromal oedema and transudation.
◦ However, some new studies suggest the fluid accumulation may be related to proteins such as
vascular endothelial growth factor (VEGF) that raise capillary permeability.

43. Difference between a Pseudomeigs’ and
Meigs’ syndrome
PSEUDOMEIGS’ SYNDROME MEIGS’ SYNDROME