A rare case of acute abdomen secondary to rupture of a Krukenberg tumor with intra- abdominal hemorrhage 三軍總醫院外科部大腸直腸外科 報告人：浦大維 1

General data Gender: female Age: 62 years old Non-smoker Multiparous woman 2

Health examination colonoscopy: a tumor at the proximal sigmoid colon. Abdominal CT: sigmoid colonic adenocarcinoma and multiple metastases in the liver. 2012/12 Laparoscopic AR pT3N1M1, KRAS wild-type Cycles of chemotherapy with FOLFIRI and cetuximab 3 3

Pre-operation CEA: 1738.09 ng/ml 2013/03, the postoperative CEA: 183.48 ng/ml 2016/04, CEA level was increased to 1001.69 ng/ml 2018/6/18

Severe and progressively intense pain in the lower abdomen Body temperature: normal BP: 80/60 mmHg, PR: 100 beats/min. Abdominal examination: muscle guarding, and rigidity WBC: 9.9 × 103/μl, N/L: 85.9/5.9%. Hb: 8 g/dl and was noted to decrease by 1.6 g/dl over a 2-h period in the emergency department. CRP level was < 0.03 mg/dl. 2016/04 5 5

Axial abdominal computed tomography scan Axial abdominal computed tomography scan. The black arrows indicate hemoperitoneum. 2018/6/18

(A) Axial abdominal CT A complex solid and cystic mass in the right adnexal area, 12.3 cm in size, was found and highly suspected to indicate ovarian metastasis (black arrow). 2018/6/18

(B) Axial abdominal CT. A complex solid and cystic mass in the left adnexal area, 8.3 cm in size, was found and highly suspected to indicate ovarian metastasis (black arrow). 2018/6/18

(C) Coronal abdominal CT (C) Coronal abdominal CT. Complex solid and cystic masses in the bilateral adnexal areas, larger on the right (black arrow), smaller on the left (white arrow), were found and were highly suspected to be ovarian metastases. Hemoperitoneum was noted (arrowhead). 2018/6/18

Axial abdominal CT of the liver. The liver metastasis was stable (black arrow). 2018/6/18

Exploratory laparotomy with salpingo-oophorectomy. (A) A large ruptured right ovarian tumor was found (14.0 × 9.5 × 4.5 cm), along with (B) a smaller left ovarian tumor (8.5 × 6.5 × 5.0 cm). Exploratory laparotomy with salpingo-oophorectomy. 2500 ml of blood and ascites and a ruptured right ovarian mass with active intra-abdominal hemorrhage were found. 2018/6/18

Conclusion: Rupture of a Krukenberg tumor with intra-abdominal hemorrhage or ovarian torsion may present as acute abdomen. Despite its rarity, this diagnosis should be considered in women presenting with acute abdomen and ovarian tumors and hemoperitoneum. 2018/6/18