QuizMe 35

Adnexal torsion

 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

  • Appendicitis
  • Ureteral stone
  • Adnexal torsion
  • Ectopic pregnancy
  • Ovarian cyst rupture
  • Negative pregnancy test
  • Normal CBC
  • Normal level of C-reactive protein.

Abdominal ultrasonography

  • Normal appendix
  •  No ureteric stones.

Transvaginal ultrasonography

  •  Normal uterus
  •  Left adnexa
  •  4 cm ovarian cyst and the whirlpool sign were seen in the right adnexa.

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.

1)         Carugno J, Naem A, Ibrahim C, Ehinger N, Moore J, Garzon S, Laganà AS. Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis. Minimally Invasive Therapy & Allied Technologies. 2021 Jan 20:1-8.

2)         Moro F, Bolomini G, Sibal M, Vijayaraghavan SB, Venkatesh P, Nardelli F, Pasciuto T, Mascilini F, Pozzati F, Leone FP, Josefsson H. Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion. Ultrasound in Obstetrics & Gynecology. 2020 Dec;56(6):934-43.

3)         Chang HC, Bhatt S, Dogra VS. Pearls and pitfalls in diagnosis of ovarian torsion. Radiographics. 2008 Sep;28(5):1355-68.

Author

Dr Antione Naem &Dr Aya Al-Shati

Reviewer

Mr Moiad Alazzam