Large Douglas Abscess with Distinctive Bilateral Salpingitis in a Young Virginal Woman 6 Months Following Small Bowel Perforation at the Level of the Jejunojejunostomy After Roux-en-Y Gastric Bypass: A Case Report.

Douglas abscesses (DA) involving the ovaries and/or fallopian tubes and tubo-ovarian abscesses (TOA) constitute a very rare finding in virginal females. Underlying conditions are suspected to play a role in their development; often however, the exact pathomechanism remains hypothetical or unknown. We report the case of a 19-year-old virginal female who was referred to our outpatient clinic for further clarification of a 6-month ongoing secondary amenorrhea. In the course of the investigations, a large Douglas abscess with distinctive bilateral salpingitis was diagnosed as an incidental finding in a basically oligosymptomatic patient. Laparoscopic abscess drainage was performed and appropriate antibiotic therapy administered. Intraoperatively collected specimens revealed Escherichia coli to be the responsible pathogen and detected foreign body giant cell reaction to intestinal contents on histopathological workup. Retrospectively, a small bowel perforation at the level of the jejunojejunostomy after Roux-en-Y gastric bypass with spillage of intestinal contents and positive cultures for Escherichia coli, 6 months prior to her referral, was identified as the triggering event. This case, however unique its pathomechanism may be, demonstrates that a history of intestinal leakage in the context of bowel surgery should be considered a relevant risk factor for the development of DA and TOA in virginal females, even if the primary cause lies several months in the past. It is under these circumstances that the clinical presentation can be atypical and misleading, making it all the more difficult to diagnose. Nonetheless, considering the possibility of this rare condition in light of medical history is crucial.