Woman with abdominal distention

An 86-year-old woman presented via ambulance to the Emergency Department after falling and being unable to get up. She reported progressive abdominal distention and weight gain over the past several years, and stated that the weight of her abdomen had prevented her from standing up after her fall. She denied pain of any kind, but did report increasing dyspnea on exertion over the last few weeks. Physical findings included massive abdominal distension with spider angiomata (Fig. 1), decreased bowel sounds, and no tenderness to palpation. While considering a diagnostic and therapeutic paracentesis, the treating physician performed a bedside abdominal ultrasound that revealed a discrete echogenic mass without evidence of ascites (Fig. 2). Computed tomography of the abdomen and pelvis with oral and intravenous contrast demonstrated a large encapsulated cystic mass filled with complex fluid (Fig. 3). The patient was admitted to the hospital and subsequently had a total abdominal hysterectomy and bilateral salpingo-oophorectomy and 80-pound tumor debulking. The pathology of the pelvic mass revealed papillary serous carcinoma, poorly differentiated grade G3, FIGO Stage 1a.