Acute Abdomen Secondary to Ileal Perforation As the Initial Presentation of Advanced Müllerian Malignancy With Hepatic Metastasis: A Case Report.

Acute abdomen in elderly postmenopausal women requires prompt evaluation to exclude life-threatening conditions such as bowel perforation, intra-abdominal sepsis, and malignancy. Advanced gynecological malignancies may involve the gastrointestinal tract, commonly through peritoneal dissemination or direct invasion. However, presentation as bowel perforation is rare and associated with significant morbidity. A 61-year-old postmenopausal woman presented with diffuse abdominal pain and altered bowel habits. She was hemodynamically unstable with clinical features of sepsis. Imaging revealed a pelvic mass with suspected bowel involvement, pneumoperitoneum, and a hepatic lesion suggestive of metastasis. Emergency exploratory laparotomy demonstrated purulent peritoneal contamination and a sloughed ileal segment near the ileocecal junction, forming a mass with adjacent pelvic structures and a hepatic lesion suggestive of metastasis. Ileal resection with end ileostomy was performed. Histopathological examination of the bowel segment and liver lesion biopsy revealed metastatic carcinomatous deposits. Immunohistochemistry showed CK7+, PAX8+, WT1+, CK20-, and SATB2-, favoring a Müllerian origin. Further imaging demonstrated advanced disease with hepatic and vertebral metastases. The patient received combination chemotherapy with gemcitabine, carboplatin, and bevacizumab, achieving a near-complete metabolic response. Bowel perforation as an initial presentation of pelvic malignancy is rare. This case highlights the importance of clinical judgment in managing an acute abdomen, especially when imaging findings are inconclusive. Immunohistochemistry plays a crucial role in identifying the primary tumor origin. Management requires a staged approach with emergency surgical intervention followed by multidisciplinary oncological treatment for optimal outcomes.