What is the management of an ovarian mass with fecaloid ascites?

Management of Ovarian Mass with Fecaloid Ascites

The management of an ovarian mass with fecaloid ascites requires immediate surgical intervention with comprehensive staging and cytoreductive surgery by a gynecologic oncologist, as this presentation strongly suggests advanced ovarian malignancy with possible bowel involvement or perforation. 1

Initial Evaluation

• Patients with ovarian masses and ascites typically present with abdominal distention, bloating, early satiety, nausea, and changes in bowel habits 1, 2
• The presence of fecaloid ascites specifically suggests:
  • Possible bowel perforation or fistula formation between the bowel and peritoneal cavity
  • Advanced ovarian malignancy with invasion into the bowel wall
  • Potential for peritonitis and sepsis requiring urgent intervention 1, 3
• Initial workup should include:
  • Comprehensive imaging with CT scan of abdomen/pelvis to assess the extent of disease 1
  • Tumor markers including CA-125, CEA, and CA 19-9 (elevated CEA may suggest gastrointestinal origin or primary mucinous ovarian tumor) 1
  • Assessment of nutritional status, as poor nutrition is associated with increased infectious complications 3

Surgical Management

• Immediate exploratory laparotomy is indicated due to the high risk of peritonitis and sepsis from fecal contamination 1, 3
• The surgical approach should include:
  1. Midline vertical incision to allow adequate access to the upper abdomen 1
  2. Aspiration of ascitic fluid for cytologic examination and culture 1
  3. Comprehensive assessment of all peritoneal surfaces 1
  4. Total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy 1
  5. Inspection and possible resection of involved bowel segments 1, 3
  6. Maximal cytoreduction with goal of no residual disease 1
  7. Pelvic and para-aortic lymph node dissection extending to the level of the renal vessels 1, 4
  8. Peritoneal washing and thorough irrigation of the abdominal cavity 1, 3

Special Considerations

• Preoperative mechanical bowel preparation should be performed if possible, as it significantly reduces infectious morbidity (p=0.01) 3
• Nutritional optimization is critical, as poor nutritional status is associated with increased infectious complications (p=0.03) 3
• Appendectomy should be performed in all cases of mucinous tumors to rule out appendiceal primary 1
• Consider placement of intraperitoneal catheter for potential postoperative intraperitoneal chemotherapy in patients with minimal residual disease 1
• Careful evaluation of the gastrointestinal tract is essential to rule out a primary gastrointestinal malignancy with ovarian metastases, particularly for mucinous tumors 1

Postoperative Management

• Broad-spectrum antibiotics covering gram-negative and anaerobic organisms should be administered 3
• Close monitoring for signs of peritonitis, sepsis, or postoperative bowel obstruction 3, 5
• Staging based on surgical findings will guide adjuvant therapy 1
• Patients with ascites and ovarian masses have a 95% positive predictive value for malignancy 6

Prognostic Considerations

• FIGO staging remains the most powerful indicator of prognosis 1
• The presence of ascites correlates with advanced stage disease - 89% of advanced stage (III and IV) ovarian cancers produce ascites, compared to only 17% of early stage disease 6
• The volume of ascites also correlates with stage - the majority (66%) of patients with stage III and IV disease have >0.5 liters of ascites 6

Common Pitfalls to Avoid

• Delaying surgical intervention when fecaloid ascites is present, as this increases risk of sepsis and mortality 3
• Attributing persistent bloating to functional gastrointestinal disorders without excluding ovarian pathology 2
• Dismissing the possibility of malignancy in the presence of normal CA-125, as early-stage disease may have normal levels in up to 50% of cases 2
• Failing to perform comprehensive surgical staging, which occurs in approximately 90% of apparent early-stage ovarian cancer cases in the United States 1