Lisa Rubinsak and Ellen L. Brock
History of present illness
A 10-year-old girl presents to the emergency room (ER) with a 4-day history of lower abdominal pain that she describes as
“constant cramping.” She also reports nausea and vomiting associated with the pain a few days ago, but this has resolved.
She was seen at another ER when the pain first started, and a CT scan there was reported as“fluid in the endometrium.” She was sent home with narcotic analgesics. She was given a follow-up appointment with a gynecologist in the community, but was not able to afford the significant copay. She is again seeking care in the ER as the pain has persisted.
Her past medical history is significant only for obesity.
She has not had her first menses but does have breast and pubic hair development. She has never had surgery. She takes no medications.
Physical examination
General appearance:Girl who is in no acute distress Vital signs:
Temperature: 39.2°C Pulse: 117 beats/min
Blood pressure: 113/64 mmHg Respiratory rate: 12 breaths/min Lungs:Clear to auscultation
Abdomen:Soft, nondistended; mildly tender to palpation in the periumbilical and suprapubic areas with no rebound or guarding
Pelvic (limited to external inspection):
Vulva: Presence of pubic hair, normal appearing virginal hymen, and no bleeding
Laboratory studies:
WBCs: 12 200/μL Hb: 10.3 g/dL Ht: 30.8%
Platelet count: 262 000/μL Sodium: 138 mEq/L Potassium: 4.3 mEq/L Chloride: 108 mmol/L HCO3-: 25 mmol/L Glucose: 122 mg/dL BUN: 6 mg/dL
Creatinine: 0.46 mg/dL
Imaging:Bedside abdominal ultrasound on admission showed uterus measuring 12.5 × 10 × 2 cm. Right ovary enlarged, measuring 6.7 × 4.9 × 4.4 cm. Fluid collection proximal to uterus measuring 4.2 × 4.8 cm. MRI is performed (Figs 80.1a,b&80.2)
How would you manage this patient?
The patient has an ovarian torsion. She was taken to the operating room for diagnostic laparoscopy, where left ovarian torsion and enlarged paratubal cyst were seen (Fig. 80.3). The patient underwent a paratubal cystectomy, and the ovarian torsion was relieved. Figure 80.4shows the appearance after the torsion was relieved, with improved color in the fallopian tube. The patient’s pain was greatly improved postoperatively and she was discharged home the day following surgery.
Pediatric ovarian torsion
Ovarian torsion occurs when adnexal structures twist on their vascular support. Typically, the ovary and fallopian tube rotate together around the broad ligament. As torsion occurs, venous and lymphatic drainage are obstructed. If ovarian torsion goes undiagnosed, arterial blood supply can become compromised.
This can ultimately result in infarction, tissue necrosis and loss of ovarian function [1].
Ovarian torsion is uncommon in the pediatric and ado- lescent population, with estimated incidence of 4.9 per 100 000 females aged 1–20 years [1]. Despite its rarity, it should always be considered in the differential diagnosis of abdominal pain, as ovarian salvage depends on early diagno- sis and surgical management. Patients typically present with acute-onset abdominal pain that is localized to one side, more commonly in the right lower quadrant [2,3]. This asymmetry could be due to the presence of the sigmoid colon in the left pelvis lessening the chance for torsion on this side [4]. It has also been proposed that patients with right-sided pain may be more likely to have surgery because of initial concerns for appendicitis [3]. Nausea and vomiting often accompany adnexal torsion. Leukocytosis and fever may indicate necrosis of the ovary, however, normal a white blood cell count does not rule out torsion [3].
Ovarian torsion is a surgical diagnosis, but imaging can often be helpful. Transvaginal ultrasound findings can vary widely in cases of torsion with rates of correct diagnosis ranging from 23 to 74% [5]. The most frequentfinding is an Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
enlarged ovary or adnexal mass [2]. The absence of adnexal blood flow on Doppler-enhanced imaging is an indicator of torsion, but normal vascularflow does not reliably rule out the diagnosis. If torsion is suspected clinically the patient should undergo laparoscopic evaluation even with normal vascular flow is present. In subacute or chronic cases with less clear clinical presentations, MRI can further assist with the diagno- sis. MRI was ordered for this patient because of her prolonged course of pain and her relatively benign exam. The most
specific MRI findings for adnexal torsion are thickening of the tube and an adnexal cystic mass with thickening of the cyst wall [6].
Over the past decade, management of ovarian torsion has moved away from surgical resection. Complete resection of ischemic appearing adnexa was previously performed because it was thought that a blue/black appearing ovary indicated irreversible necrosis. There was also a fear that simple relief of the torsion (“untwisting” the ovary on its pedicle) could
Fig. 80.2 Transverse MRI imaging shows the uterus (arrowhead), ovary (arrow) and paratubal cyst (star).
Fig. 80.3 Appearance at laparoscopy of adnexal torsion. Note the twisted infundibulopelvic ligament and the engorged ovary atop the large paratubal cyst.
(a) (b)
Fig. 80.1 (a,b) Sagittal MRI imaging shows an engorged ovary with an adjacent tubal structure.
Case 80: A 10-year-old girl with lower abdominal pain
leave a malignancy in situ or dislodge a thrombus from pelvic veins and cause a thromboembolic complication [2,4]. More recent studies have shown that the intraoperative appearance of the adnexa does not correlate with recovery of ovarian function. In a case series of ovarian torsion patients, all 14 patients who followed up postoperatively were found to have functional ovaries on ultrasound or biopsy despite intra- operative ovarian appearance described as worrisome for mod- erate to severe ischemia [7]. Similarly, Celik and colleagues found successful return of normal ovarian function in 13 of 14 patients who had relief of torsion despite necrotic appearance on gross examination [8]. Studies have also shown that throm- boembolic complications are extremely rare. Since 1900, there have been two reported cases of pulmonary embolism associ- ated with ovarian torsion following adnexal resection and no reports of thromboembolism following simple relief of torsion [4]. Malignancy risk in pediatric ovarian torsion cases is also low and data suggest that presence of an ovarian mass should not deter attempted ovarian salvage. Incidence of malignant
neoplasm has been estimated at less than 0.5% of all cases of torsion in the pediatric population [1].
Timely diagnosis and surgical intervention is important in ovarian conservation. The amount of time from torsion to permanent ovarian necrosis is unknown. There are animal studies that demonstrate ovarian reperfusion following relief of torsion if time to intervention was less than 36 hours [3]. In a case series of 22 ovarian torsion patients, those operated on within 8 hours of initial presentation had a salvage rate of 40%, while those operated on within 24 hours had a salvage rate of 33%, and those whose operative intervention was more than 24 hours after initial presentation had no ovaries salvaged [9].
While the differences in ovarian salvage rates were not statis- tically significant in the study, the trend suggests the import- ance of early surgical management. The same study also found no correlation between duration of symptoms and ovarian infarction. An ovary can undergo intermittent torsion where adnexal structures twist followed by an uncoiling and reperfu- sion. This alternating cycle can present as prolonged symp- toms prior to diagnosis, but can result in continued viability of ovarian tissue. With no exact time known to cause permanent ovarian necrosis, prolonged pain prior to presentation should not deter prompt evaluation and surgical intervention.
Key teaching points
Ovarian torsion should be considered in any woman with lower quadrant abdominal pain.
The most commonfinding on ultrasound is an enlarged ovary or adnexal mass.
Normal vascularflow to the ovary on ultrasound does not rule out the diagnosis of ovarian torsion.
MRI or CT may be useful in an unclear clinical presentation with subacute or chronic symptoms.
If there is clinical suspicion of torsion, operative intervention should occur in a timely manner.
Current recommendations for treatment are conservative management with relief of the torsion alone regardless of the gross appearance of the ovary.
Risks of malignancy and thromboembolic events are very low and should not deter attempted ovarian conservation.
References
1. Guthrie BD, Adler MD, Powell EC.
Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000–2006.Pediatrics 2010;125:532–8.
2. Poonai N, Poonai C, Lim R, Lynch T.
Pediatric ovarian torsion: case series and review of the literature.Can J Surg 2013;56:103–8.
3. Rossi BV, Ference EH, Zurakowski D, et al. The clinical presentation and surgical management of adnexal torsion in the pediatric
and adolescent population.J Pediatr Adolesc Gynecol2012;25:109–13.
4. Tsafrir Z, Azem F, Hasson J, et al. Risk factors, symptoms, and treatment of ovarian torsion in children: the twelve- year experience of one center.J Minim Invasive Gynecol2012;19:29–33.
5. Mashiach R, Melamed N, Gilad N, Ben-Shitrit G, Meizner I. Sonographic diagnosis of ovarian torsion: accuracy and predictive factors.J Ultrasound Med2011;30:1205–10.
6. Rha SE, Byun JY, Jung SE, et al. CT and MR imaging features of adnexal
2002;22:283–94.
7. Aziz D, Davis V, Allen L, Langer J.
Ovarian torsion in children: Is oophorectomy necessary?J Pediatr Surg 2004;39(5):750–3.
8. Celik, A. Ergun O, Aldemir H, et al.
Long-term results of conservative management of adnexal torsion in childrenJ Pediatr Surg2005;40(4):
704–8.
9. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients.
Arch Pediatr Adolesc Med2005;159:
532–5.
Fig. 80.4 Appearance of the pelvis following relief of the torsion and removal of the paratubal cyst. The ovary is still enlarged but the engorgement and purple color are already resolving.