A 27-year-old nulligravidae patient presented at the A&E complaining of acute abdominal pain. The pain is localized at the right lower abdominal quadrant with a 2 hr. duration. The patient is afebrile, conscious, and responsive. She has no chronic diseases or previous surgeries. The patient mentioned that over the last week she had multiple episodes of abdominal pain that resolved spontaneously. The clinical examination was inconclusive, with tenderness over the right lower quadrant as the sole finding
- Ureteral stone
- Adnexal torsion
- Ectopic pregnancy
- Ovarian cyst rupture
- Negative pregnancy test
- Normal CBC
- Normal level of C-reactive protein.
Color Doppler ultrasonography
Normal ovarian perfusion
Since the lab results and the imaging findings were misleading, an exploratory laparoscopy was performed. The right ovary was found to be torsed and bluish in appearance. The left ovary and fallopian tube were unremarkable
Detorsion of the right ovary was performed. Fifteen minutes after detorsion, the ovary retained its white color. Ovarian cystectomy and ovariopexy were performed.
Ovarian torsion occurs when the ovary twists around the axis between the infundibulo-pelvic ligament and the ovarian ligament. Ovarian torsion usually occurs in enlarged ovaries due to ovarian cysts, polycystic ovarian syndrome, or ovarian hyperstimulation syndrome. Ovaries with endometriomas are the least likely to torse due to adhesions. Although rare, torsion of a normal ovary usually occurs in children. It is noteworthy that episodes of ovarian torsion and spontaneous detorsion may occur, causing intermittent abdominal pain.
Ovarian torsion causes the ovarian vasculatures to twist and impairs the venous blood flow subsequently. Impaired venous flow leads to ovarian stromal edema and increased intra-ovarian pressure. Eventually, the intra-ovarian pressure exceeds the arterial pressure and leads to ischemia. Therefore, ovarian torsion is progressive disease and an absent flow on color Doppler ultrasonography is only present at late stages. The whirlpool sign is simply the ultrasonographic appearance of the torsed adnexa. It is encountered in 91% of cases, whereas a negative Doppler flow is seen in nearly 13% of cases.
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