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Description
Peritoneal loose bodies are asymptomatic free intraperitoneal masses, typically found incidentally. Their aetiology is attributed to torsion and separation of the appendices epiploicae; histology usually shows fibrous tissue.1 We report a case of ectopic pregnancy with a co-incidental finding of a peritoneal loose body at the time of laparoscopy.
A 30-year-old woman with a history of two previous ectopic pregnancies, both managed medically with methotrexate, presented with a positive pregnancy test and acute lower abdominal pain. A diagnosis of a right-sided ectopic pregnancy was made on transvaginal ultrasound. In view of her pain, she was treated surgically. Laparoscopy showed a 30×20×10 mm unattached cystic structure in the vesicouterine pouch (figure 1), in addition to a ruptured right ampullary ectopic pregnancy. Histologically, the cystic structure had degenerate decidua remnants at its core (figure 1).
Left: laparoscopic image of 30×20×10 mm peritoneal loose body. Right: light microscopy image showing necrotic material (A) and decidual remnants (B).
The histology suggests that the peritoneal loose body represented one of the two previous ectopic pregnancies, which had been expelled (spontaneously or as a result of methotrexate) into the peritoneal cavity. This represents the first case of a peritoneal loose body arising from a previous medically managed ectopic pregnancy.
The peritoneal loose body may represent an early lithopaedion (an advanced abdominal pregnancy retained within the peritoneum, which has become calcified).2 Santoro et al hypothesise that abnormal fallopian contractions may lead to intraperitoneal expulsion of the embryo, resulting in lithopaedion. We propose that the peritoneal loose body described may similarly have arisen due to abnormal fallopian contractions and may have become calcified at a more advanced gestation.
Learning points
This represents a new aetiology for peritoneal loose body, which has previously been thought to originate only from the separation of appendices epiploicae.
The peritoneal loose body may represent an early lithopaedion (calcified extrauterine pregnancy).
This case provides insight into the pathophysiology of tubal ectopic pregnancy.
Acknowledgments
The authors would like to thank Rebecca Gillibrand for her assistance in obtaining and interpreting the light microscopy image.
Footnotes
Contributors WRC obtained the images, completed the literature search, and wrote and edited the manuscript. EK conceived the case report, gained patient consent and edited the manuscript.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.