Difference between revisions of "Ovarian torsion"

(intermittent pain in ovarian torsion)
(Doppler Ultrasound)
 
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==Background==
 
==Background==
*Occurs in females of all ages (most common in reproductive age women)
+
*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
*Ovarian cysts and neoplasms account for 94% of cases in adults
+
*Referred to as adnexal torsion and tubo-ovarian torsion
**Account for only 50% in children (much more likely to torse normal ovaries)
+
*Occurs in females of all ages
 +
**Most common in reproductive age adults
 +
**In children, it is most common in 9-14 years of age
 +
**Risk factors:
 +
***Ovarian mass
 +
***Fertility treatments
 +
*Ovarian cysts (usually > 4 cm) and neoplasms account for 94% of cases in adults<ref>Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235</ref>
 +
*Torsion more common on the right, as the sigmoid colon tends to stabilize the left
 +
*In children, hypermobility of the ovary many be the primary cause of torsion
 +
*Dual blood supply from ovarian and uterine arteries
 +
 
 +
===Pathophysiology===
 +
Torsion occurs from either of two causes:
 +
#Hypermobility of the ovary
 +
#Adnexal mass
 +
*Cysts greater than 4 cm are more likely to torse<ref>M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282</ref>
 +
*Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion
  
 
==Clinical Features==
 
==Clinical Features==
*Nausea/vomiting ~ 70%
+
*[[Nausea/vomiting]] (70%)
*Sudden and sharp pain in the lower abdomen ~ 59%
+
*Sudden and sharp pain in the lower abdomen (50%)<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
** can be intermittent
+
**Can be intermittent and insiduous, especially in those with history of cysts, PCOS<ref>Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.</ref>
*Fever ~ <2%
+
**Commonly occurs simultaneously with vomiting
 +
**May occur for days to months intermittently before diagnosis is made<ref>Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.</ref>
 +
*Up to 30% have no tenderness on bimanual exam<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
 +
*Most adults with ovarian torsion have abnormal or enlarged ovaries that serves as lead point for torsion, but torsion is more likely to occur in normal sized ovaries in pediatrics<ref>Anders, J.F. and Powell, E.C. Urgency and evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159: 532–535.</ref>
 +
**More than 50% of cases have no palpable adnexal mass<ref>Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.</ref>
 +
*[[Fever]] (<2%)
 +
*Up to 20% of cases seen in pregnant women, with most in the 1st trimester and/or received fertility treatments<ref>Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.</ref>
 +
 
 +
==Differential Diagnosis==
 +
{{Abd DDX RLQ}}
 +
 
 +
{{LLQ DDX}}
 +
 
 +
==Evaluation==
 +
===Pelvic exam===
 +
*May not have adnexal TTP or adnexal mass
  
==DDx==
+
===Doppler [[Ultrasound]]===
*[[Ectopic Pregnancy]]
+
[[File:PMC4603210 usg-15013-f10.png|thumb|Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.]]
*Ruptured or hemorrhagic cyst
+
Findings suggestive of torsion may include:
*[[Appendicitis]]
+
*Diminished or absent blood flow in the ovarian vessels<ref name="Lee">Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.</ref>
*[[PID]]
+
**2/3 of patients with ovarian torsion have had normal blood flow
*Fibroid (degenerating)
+
**Venous and lymphatic obstruction occurs before arterial disruption, especially early in disease process<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
*Endometriosis
+
**Abnormal blood flow, whether venous or arterial, is ~85% sensitive, ~37% specific when not combined with below findings<ref>Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.</ref>
 +
*Enlarged ovarian volume
 +
**'''MC finding'''
 +
**''A maximum ovarian diameter (MOD) < 3cm in a postmenarchal patient is unlikely to represent ovarian'' torsion<ref>Budhram G, Elia T, Dan J, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159.</ref>
 +
*Loss of echogenicity
 +
*Peripherally displaced follicles with hyperechoic central stroma
 +
*Midline ovary
 +
*Pelvic free fluid
 +
*An infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration
 +
*Whirlpool sign of twisted vascular pedicle may be seen but rare<ref name="Lee"></ref>
  
==Diagnosis==
+
===CT Abd/Pelvis===
*Ultrasound
+
*CT has a low sensitivity for torsion
**Diminished or absent blood flow in the ovarian vessels
+
**Examine for asymmetric ovarian enlargement, which warrants a pelvic US if concerning symptoms exist<ref>Lourenco, A.P., Swenson, D., Tubbs, R.J. et al. Ovarian and tubal torsion: imaging findings on US, CT and MRI. Emerg Radiol. 2014; 21: 179–187.</ref>
**Ovarian mass
+
*CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass
  
==Treatment==
+
==Management==
 
*Emergent OB/GYN consult in ED
 
*Emergent OB/GYN consult in ED
 +
**Consider if high suspicion exists even after equivocal US
 +
*Surgical detorsion is required to prevent ovarian necrosis
 +
**If the ovary becomes necrotic, there is a high risk of infection
 +
**Salvage rate may be high even if time is prolonged beyond several hours of symptoms<ref>Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535</ref>
  
==Source==
+
==See Also==
*UpToDate
+
*[[Abdominal pain]]
  
[[Category:OB/GYN]]
+
==References==
 +
<references/>
 +
[[Category:OBGYN]]

Latest revision as of 18:59, 1 July 2019

Background

  • Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle
  • Referred to as adnexal torsion and tubo-ovarian torsion
  • Occurs in females of all ages
    • Most common in reproductive age adults
    • In children, it is most common in 9-14 years of age
    • Risk factors:
      • Ovarian mass
      • Fertility treatments
  • Ovarian cysts (usually > 4 cm) and neoplasms account for 94% of cases in adults[1]
  • Torsion more common on the right, as the sigmoid colon tends to stabilize the left
  • In children, hypermobility of the ovary many be the primary cause of torsion
  • Dual blood supply from ovarian and uterine arteries

Pathophysiology

Torsion occurs from either of two causes:

  1. Hypermobility of the ovary
  2. Adnexal mass
  • Cysts greater than 4 cm are more likely to torse[2]
  • Absence of ovarian Doppler flow is highly specific for torsion, but normal Doppler flow does not completely exclude torsion

Clinical Features

  • Nausea/vomiting (70%)
  • Sudden and sharp pain in the lower abdomen (50%)[3]
    • Can be intermittent and insiduous, especially in those with history of cysts, PCOS[4]
    • Commonly occurs simultaneously with vomiting
    • May occur for days to months intermittently before diagnosis is made[5]
  • Up to 30% have no tenderness on bimanual exam[6]
  • Most adults with ovarian torsion have abnormal or enlarged ovaries that serves as lead point for torsion, but torsion is more likely to occur in normal sized ovaries in pediatrics[7]
    • More than 50% of cases have no palpable adnexal mass[8]
  • Fever (<2%)
  • Up to 20% of cases seen in pregnant women, with most in the 1st trimester and/or received fertility treatments[9]

Differential Diagnosis

RLQ Pain

LLQ Pain

Evaluation

Pelvic exam

  • May not have adnexal TTP or adnexal mass

Doppler Ultrasound

Gray-scale (A) and power Doppler (B) sonograms show the swirling of the ovarian vascular pedicle, the “whirlpool sign,” in a case of ovarian torsion.

Findings suggestive of torsion may include:

  • Diminished or absent blood flow in the ovarian vessels[10]
    • 2/3 of patients with ovarian torsion have had normal blood flow
    • Venous and lymphatic obstruction occurs before arterial disruption, especially early in disease process[11]
    • Abnormal blood flow, whether venous or arterial, is ~85% sensitive, ~37% specific when not combined with below findings[12]
  • Enlarged ovarian volume
    • MC finding
    • A maximum ovarian diameter (MOD) < 3cm in a postmenarchal patient is unlikely to represent ovarian torsion[13]
  • Loss of echogenicity
  • Peripherally displaced follicles with hyperechoic central stroma
  • Midline ovary
  • Pelvic free fluid
  • An infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration
  • Whirlpool sign of twisted vascular pedicle may be seen but rare[10]

CT Abd/Pelvis

  • CT has a low sensitivity for torsion
    • Examine for asymmetric ovarian enlargement, which warrants a pelvic US if concerning symptoms exist[14]
  • CT may be used to rule out other possible causes of lower abdominal pain; also exclude presence of pelvic mass

Management

  • Emergent OB/GYN consult in ED
    • Consider if high suspicion exists even after equivocal US
  • Surgical detorsion is required to prevent ovarian necrosis
    • If the ovary becomes necrotic, there is a high risk of infection
    • Salvage rate may be high even if time is prolonged beyond several hours of symptoms[15]

See Also

References

  1. Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235
  2. M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282
  3. Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
  4. Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.
  5. Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.
  6. Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
  7. Anders, J.F. and Powell, E.C. Urgency and evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005; 159: 532–535.
  8. Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
  9. Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.
  10. 10.0 10.1 Lee EJ et-al. Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle. J Ultrasound Med. 1998;17 (2): 83-9.
  11. Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
  12. Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
  13. Budhram G, Elia T, Dan J, et al. A Case-Control Study of Sonographic Maximum Ovarian Diameter as a Predictor of Ovarian Torsion in Emergency Department Females With Pelvic Pain. Acad Emerg Med. 2019;26(2):152-159.
  14. Lourenco, A.P., Swenson, D., Tubbs, R.J. et al. Ovarian and tubal torsion: imaging findings on US, CT and MRI. Emerg Radiol. 2014; 21: 179–187.
  15. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535