Ovarian torsion: Difference between revisions
Neil.m.young (talk | contribs) (Text replacement - "== " to "==") |
ClaireLewis (talk | contribs) No edit summary |
||
(19 intermediate revisions by 5 users not shown) | |||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Ovarian torsion is the rotation of the ovary and portion of the fallopian tube on the supplying vascular pedicle | *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 | *Occurs in females of all ages | ||
**Most common in reproductive age adults | **Most common in reproductive age adults | ||
**In children | **In children, it is most common in 9-14 years of age | ||
*Ovarian cysts (usually > | **Risk factors: | ||
*Torsion more common on the right, sigmoid tends to stabilize the left | ***Ovarian mass | ||
*In children hypermobility of the ovary many be the primary cause of torsion | ***Fertility treatments | ||
*Dual blood supply from | *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=== | ===Pathophysiology=== | ||
Torsion occurs from either of | Torsion occurs from either of two causes: | ||
#Hypermobility of the ovary | #Hypermobility of the ovary | ||
#Adnexal mass | #Adnexal mass | ||
*Cysts greater than | *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 | *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 ( | *Sudden and sharp [[abdominal pain|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> | ||
**Commonly occurs simultaneously with vomiting | **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%) | *[[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== | ==Differential Diagnosis== | ||
Line 28: | Line 37: | ||
{{LLQ DDX}} | {{LLQ DDX}} | ||
== | ==Evaluation== | ||
=== | ===Doppler [[Ultrasound]]=== | ||
[[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.]] | |||
Findings suggestive of torsion may include: | Findings suggestive of torsion may include: | ||
*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> | *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> | ||
**2/3 of patients with ovarian torsion have had normal blood flow. | **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<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> | ||
**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 | *Enlarged ovarian volume | ||
**'''MC finding''' | **'''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 | *Loss of echogenicity | ||
*Peripherally displaced follicles with hyperechoic central stroma | *Peripherally displaced follicles with hyperechoic central stroma | ||
Line 49: | Line 57: | ||
===CT Abd/Pelvis=== | ===CT Abd/Pelvis=== | ||
*CT | *CT has a low sensitivity for torsion | ||
*CT may be used to | **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> | ||
*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 | *Emergent OB/GYN consult in ED | ||
** | **Consider if high suspicion exists even after equivocal US | ||
*Surgical detorsion is required to prevent ovarian necrosis | *Surgical detorsion is required to prevent ovarian necrosis | ||
**Salvage rate may be high even if prolonged | **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> | |||
==See Also== | ==See Also== |
Revision as of 01:45, 4 October 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:
- Hypermobility of the ovary
- 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]
- 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
- GI
- Appendicitis
- Perforated appendicitis
- Peritonitis
- Crohn's disease (terminal ileitis)
- Diverticulitis (cecal, Asian patients)
- Inguinal hernia
- Mesenteric ischemia
- Ischemic colitis
- Meckel's diverticulum
- Neutropenic enterocolitis (typhlitis)
- Appendicitis
- GU
- Other
LLQ Pain
- Diverticulitis
- Kidney stone
- UTI
- Pyelonephritis
- Ectopic pregnancy
- Infectious colitis
- Inflammatory bowel disease (Crohn's Disease, Ulcerative Colitis)
- Inguinal hernia
- Mesenteric ischemia
- Epiploic appendagitis
- Mittelschmerz
- Ovarian cyst
- Ovarian torsion
- PID
- Psoas abscess
- Testicular torsion
- Appendicitis
- Abdominal aortic aneurysm
- Herpes zoster
- Endometriosis
- Colon cancer
- Irritable bowel syndrome
- Small bowel obstruction
Evaluation
Doppler Ultrasound
Findings suggestive of torsion may include:
- Diminished or absent blood flow in the ovarian vessels[10]
- 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
- ↑ Amirbekian S et al. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235
- ↑ M.L. Brandt et al. Surgical indications in antenatally diagnosed ovarian cysts J Pediatr Surg, 26 (1991), pp. 276–282
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ Damigos, E., Johns, J., and Ross, J. An update on the diagnosis and management of ovarian torsion. Obstet Gynaecol. 2012; 14: 229–236.
- ↑ Sasaki, K.J. and Miller, C.E. Adnexal torsion: review of the literature. J Minim Invasive Gynecol. 2014; 21: 196–202.
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ 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.
- ↑ Houry, D. and Abbott, J.T. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001; 38: 156–159.
- ↑ Albayram, F. and Hamper, U.M. Ovarian and adnexal torsion: spectrum of sonographic findings with pathologic correlation. J Ultrasound Med. 2001; 20: 1083–1089.
- ↑ 10.0 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.
- ↑ Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
- ↑ Cicchiello, L.A., Hamper, U.M., and Scoutt, L.M. Ultrasound evaluation of gynecologic causes of pelvic pain. Ultrasound Clin. 2010; 38: 85–114.
- ↑ 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.
- ↑ 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.
- ↑ Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159:532–535