Case of the Month – July 2018

By Dr Greg Amos

Patient history

This 63 year old male patient presented to his GP with generalized nausea, abdominal pain and weight loss. A recent US abdomen and routine blood tests were normal. The patient had a long history of intermittent bilateral hip pain with multiple pelvic x-rays and hip ultrasounds performed.

Imaging and findings

A CT abdomen and pelvis with intravenous contrast was performed. This demonstrated two calcifying rounded foci in an intraperitoneal loation within the rectovesical pouch in the pelvis, one densely calcified and one showing lamellation (see image 1).

In retrospect, the densely calcified focus has been noted on x-rays dating back 8 years (see image 2), mobile in its position. A bladder stone had been suggested as the diagnosis but excluded with a follow up ultrasound.

Discussion and Management

The findings were consistent with peritoneal loose bodies. These are thought to form from torsed, infarcted epiploic appendages that amputate their pedicle and float freely in the intraperitoneal cavity. They slowly transform into fibrotic calcified masses through saponification. These bodies are mostly pelvic in location, gravitating to the most dependent part of the abdominal cavity. Most are small, less than 2cm but bodies up to 8cm have been described.

Such masses are often asymptomatic when small but can produce local inflammation and have been associated with non-specific migrating abdominal pain. When large enough they can cause extrinsic compression that is associated with bowel obstruction, urinary retention, or urinary frequency. Treatment is laproscopic removal.

COM Jul2018