Can a ruptured right ovarian cyst cause pleural effusion, mild abdominal fluid, and right lower quadrant pain with minimal rebound tenderness?

Ruptured Ovarian Cyst Causing Pleural Effusion, Abdominal Fluid, and Right Lower Quadrant Pain

Yes, a ruptured right ovarian cyst can cause pleural effusion, mild abdominal fluid, and right lower quadrant pain with minimal rebound tenderness, representing a recognized complication of ovarian cyst rupture.

Pathophysiology and Clinical Presentation

A ruptured ovarian cyst typically presents with:

• Acute onset of unilateral lower abdominal pain (commonly in the right lower quadrant when the right ovary is involved)
• Mild abdominal fluid (hemoperitoneum) from bleeding into the peritoneal cavity
• Minimal rebound tenderness due to peritoneal irritation from blood and cyst contents
• Pleural effusion in some cases (due to transdiaphragmatic migration of fluid)

The American College of Radiology (ACR) guidelines note that findings of "irregular peripherally enhancing adnexal cyst usually accompanied by hemorrhagic pelvic free fluid might indicate a ruptured hemorrhagic cyst" 1. This is a recognized gynecological etiology of acute pelvic pain.

Diagnostic Considerations

When evaluating a patient with these symptoms:

1. Ultrasound is the first-line imaging modality:

   • ACR recommends ultrasound as the initial imaging for acute pelvic pain, particularly for suspected gynecological causes 1, 2
   • Can detect free fluid in the abdomen but may have limitations in definitively identifying cyst rupture

2. CT findings in ruptured ovarian cysts:

   • Different effusion density between pelvic cavity and upper abdomen
   • Direct visualization of the cystic mass
   • Irregularity of opacified cystic walls (sign of rupture)
   • Extravasation of contrast material in the pelvic cavity 3

3. Pleural effusion connection:

   • While not explicitly mentioned in most guidelines for uncomplicated cases, intraperitoneal fluid can migrate across the diaphragm in significant hemorrhage cases
   • This transdiaphragmatic migration can result in pleural effusion, particularly on the right side

Differential Diagnosis

Important conditions to rule out include:

• Appendicitis (most common non-obstetric surgical emergency in pregnancy) 2
• Ectopic pregnancy (must be excluded with β-hCG testing) 1
• Pelvic inflammatory disease/tubo-ovarian abscess 1
• Adnexal torsion 1, 4
• Other causes of hemoperitoneum

Management Approach

Management should be guided by the patient's clinical status:

1. For hemodynamically stable patients with minimal symptoms:

   • Conservative management with analgesics and monitoring
   • Most cases of ruptured functional cysts are self-limiting 4

2. For significant hemorrhage or diagnostic uncertainty:

   • Laparoscopic evaluation may be necessary 4
   • Peritoneal washout and/or cyst removal if bleeding persists 5

3. For recurrent episodes:

   • Consider ovulation suppression with combined oral contraceptives to prevent recurrence 4

Important Clinical Considerations

• The diagnosis of hemoperitoneum from ruptured ovarian cyst can be missed or misdiagnosed as other conditions like ectopic pregnancy 6
• The presence of pleural effusion with abdominal pain should prompt consideration of transdiaphragmatic migration of peritoneal fluid
• Ultrasound may show free fluid but might not definitively identify the ruptured cyst in all cases
• CT imaging can provide more definitive diagnosis when ultrasound is inconclusive 3

Clinicians should maintain a high index of suspicion for ovarian cyst rupture in women of reproductive age presenting with acute lower abdominal pain, particularly when associated with free intraperitoneal fluid and pleural effusion.