Presentation
Acute ovarian torsion is an uncommon yet important diagnostic consideration in any female pediatric patient presenting with acute abdominal pain. A 2-month-old infant presented to the emergency department with a several-day history of constipation. [ncbi.nlm.nih.gov]
Entire Body System
- Severe Pain
Twisting causes sudden, severe pain and often vomiting. Doctors use an ultrasound device inserted into the vagina (transvaginal ultrasonography) to confirm the diagnosis. Surgery is done immediately to untwist the ovary or to remove it. [msdmanuals.com]
Mild pain in your belly can last for several weeks, but if you have moderate to severe pain that makes it very hard for you to walk, you vomit, or you feel like passing out, see your HCP right away or go to the closest emergency room. [youngwomenshealth.org]
Patient usually presents with acute severe pain abdomen and pelvic examination may reveal a tender cystic mass separate from the uterus. The risk of ovarian torsion rises by 5 fold during pregnancy. Incidence is 5 per 10,000 pregnancies[ 1 ]. [casesjournal.biomedcentral.com]
Discussion Ovarian torsion is an uncommon cause of acute abdominal pain in nonpregnant women but is more common during pregnancy. When present, it is often associated with severe pain. [mdmag.com]
- Ascites
Only chylous ascites was discovered in the operative field. She underwent a complete abdominal hysterectomy and salphingo-oophorectomy. Only saline irrigation and suction-up were performed for the chylous ascites. [ncbi.nlm.nih.gov]
The ten "Simple Rules" are five ultrasound features indicative of benign cysts (B-features) and five ultrasound features indicative of a malignant cysts (M-features) based on the presence of tumor morphology, degree of vascularity, and ascites ( Table [clevelandclinicmeded.com]
The enlarged stimulated ovaries, floating in the pelvic ascites, may explain this association. [academic.oup.com]
Any patient with an M-rule should be referred to a gynaecologist. 4,5 The presence of ascites has a positive predictive value of 95% for ovarian cancer. 6 Table 1. [racgp.org.au]
- Falling
This enlargement was accompanied with platelets' fall and the possibility of repeated torsion impended. Thrombocytopenia was suspected from the first moment, but diagnosed after the surgery. [ncbi.nlm.nih.gov]
“Some cysts, when they become big, can fall behind the uterus, and in that case are sitting right by your cervix,” says Dr Chapman-Davis. “So you might feel pain with deep penetration.” [health24.com]
Fall in blood pressure and heart rate is another common response to visceral and deep somatic nociception. 7 Ultrasound is the diagnostic modality of choice and will most often reveal a unilateral ovarian enlargement that appears solid, cystic, or complex [mdmag.com]
Histories fall into two categories, typical and atypical. Typical appendicitis includes several hours of generalized abdominal pain that begins in the region of the umbilicus with associated anorexia, nausea, or vomiting. [en.wikipedia.org]
Gastrointestinal
- Abdominal Pain
Abdominal pain is one of the most common chief complaints of patients presenting to emergency departments, and emergency physicians (EPs) often evaluate patients with right lower quadrant abdominal pain. [ncbi.nlm.nih.gov]
- Nausea
A middle-aged female presented with a 5-day history of cramping abdominal pain and nausea and vomiting. Abdominal wall guarding and rebound tenderness was noted on examination. [ncbi.nlm.nih.gov]
Listen for key features on history: sudden onset of unilateral pelvic pain, sometimes radiating to the groin, often associated with nausea and vomiting. [cdemcurriculum.com]
Other symptoms may include nausea. Complications may include infection, bleeding, or infertility.Risk factors include ovarian cysts, ovarian enlargement, ovarian tumors, pregnancy, fertility treatment, and prior tubal ligation. [en.wikipedia.org]
- Lower Abdominal Pain
Given the higher risk of malignancy in post-menopausal women, ovarian mass-related torsion is an uncommon but important cause of acute-onset lower abdominal pain. [ncbi.nlm.nih.gov]
Ovarian cysts Lower abdominal pain with adnexal fullness on exam. Imaging or laparoscopy may be needed to distinguish from ovarian torsion. Ultrasound shows ovarian cysts and lacks features suggestive of torsion. [online.epocrates.com]
- Acute Abdomen
A 33-year-old woman was admitted to our hospital owing to acute abdomen. Nine days previously, she had had a stillbirth caused by hydrops fetalis at 24 weeks' gestation. [ncbi.nlm.nih.gov]
Although our patient presented with acute left-sided abdominal pain and vomiting, early diagnosis could not be made due to the late referral. Imaging is frequently used in the management of an acute abdomen. [mjdrdypv.org]
Ectopic pregnancy Reproductive-age, sexually active female with missed menses, lower abdominal and pelvic pain, and symptoms of acute abdomen such as diarrhea, nausea, and vomiting. Presentation may be difficult to distinguish from ovarian torsion. [online.epocrates.com]
- Pelvic Mass
Although uncommon, pelvic masses that are benign may mimic malignant masses with extradnexal inflammation. [ncbi.nlm.nih.gov]
In cases of isolated tubal torsion, the affected fallopian tube is distended and appears as a cystic pelvic mass with normal ovarian flow. Color Doppler features: 90% of the affected ovaries have abnormal color Doppler findings. 1. [sonoworld.com]
Are ovarian cysts and pelvic masses the same? Pelvic masses are defined as an abnormal growth in the pelvic cavity. This can be a growth or tumor in the ovaries, uterus or any pelvic organ. [drseckin.com]
No masses, distention or tenderness were detected. Pelvic exam was conducted and was noted to have no vaginal discharge or bleeding, and no pelvic masses were appreciated by the provider. However, it was noted that body habitus limited the exam. [westjem.com]
Cardiovascular
- Thrombosis
[…] by the prominent susceptibility-induced signal void caused by the thrombosis. [ncbi.nlm.nih.gov]
Arterial thrombosis and ultimately ischemia and infarction ensue. If torsion is left untreated, systemic infection and inflammation may occur (, 11, , 15, , 18, , 19 ). [pubs.rsna.org]
The increased pressure results in thrombosis and occlusion of the small vessels, and stasis of lymphatic flow. At this point spontaneous recovery rarely occurs. [en.wikipedia.org]
- Tachycardia
Physical examination should include vital signs, which can show tachycardia, hypertension, hypotension, or even fever. [emdocs.net]
Neurologic
- Headache
The patient had no previous history of similar episodes in the past and denied fever, chills, headache, dysuria, constipation, diarrhea, menorrhagia or dysmenorrhea. [omicsonline.org]
Constitutional symptoms such as fatigue, headaches Nausea or vomiting Weight gain Other symptoms may depend on the cause of the cysts: [4] Symptoms that may occur if the cause of the cysts is polycystic ovarian syndrome (PCOS) may include increased facial [en.wikipedia.org]
Urogenital
- Adnexal Mass
Important questions regarding medical history include the presence of adnexal mass, gynecologic or obstetric diseases, pregnancy, ongoing infertility treatment, and prior adnexal mass. [emdocs.net]
View Article PubMed Google Scholar Duic Z, Kukura V, Ciglar S, et al: Adnexal masses in pregnancy: a review of eight cases undergoing surgical management. Eur J Gynaecol Oncol. 2002, 23: 133-134. PubMed Google Scholar Hibbard LT: Adnexal torsion. [casesjournal.biomedcentral.com]
Another 10-year study showed that 15% of 135 patients with surgically treated adnexal masses had torsion [20]. Totally, around 2%–15% of patients who had surgical treatment of adnexal masses had ovarian torsion. [tcmjmed.com]
Among 44 postmenopausal patients with acute pelvic masses, 10 cases with adnexal torsion were selected. The exclusion criteria were adnexal masses without torsion, non-menopausal status and inadequate data. [jmrh.mums.ac.ir]
The affected ovary may show a heterogeneous echotexture and may be seen as a complex adnexal mass with septations and debris, as a cystic mass or as a solid mass with peripheral cysts. 3. [sonoworld.com]
- Adnexal Tenderness
Physical examination may reveal lower abdominal tenderness. On pelvic exam, the patient may have adnexal tenderness or an adnexal mass. Fever is uncommon, and usually low-grade if present. [cdemcurriculum.com]
Pelvic inflammatory disease Sexually active female with lower abdominal pain, cervical motion tenderness, and adnexal tenderness. Abnormal vaginal and cervical discharge may be noted, as well as a temperature >101°F (>38°C). [online.epocrates.com]
There is adnexal tenderness. A raised white cell count is common. The result of vascular compromise secondary to ovarian torsion is hemorrhagic infarction and necrosis, that can occur as rapidly as within hours of torsion onset. [radiopaedia.org]
The most common presenting symptom/sign was lower abdominal pains/adnexal tenderness (100%) and none presented with anemia or deranged blood chemistry. Most (66%) had the cyst on the right. [tjogonline.com]
Workup
Her subsequent workup suggested AT necessitating a laparoscopic evaluation where right adnexectomy was carried out due to hemorrhagic and necrotic changes. [scitechnol.com]
Abdominal Loin pain hematuria syndrome Proctitis —infection or inflammation of the anus or rectum Colitis —infection or inflammation of the colon Appendicitis —infection or inflammation of the bowel Diagnosis [ edit ] Females [ edit ] The diagnostic workup [en.wikipedia.org]
[…] to and treatment by gynecologic oncologists has been shown to improve survival rates in women with ovarian cancer. 14-16 Cysts with an Indeterminate Likelihood of Malignancy For women with cysts with an intermediate likelihood of malignancy, further workup [clevelandclinicmeded.com]
X-Ray
- Nephrolithiasis
Signs and symptoms often mimic other disorders such as appendicitis, pyelonephritis, and nephrolithiasis. The diagnosis becomes more challenging in that torsion can occur in female patients of all ages, including infants and the elderly. [ncbi.nlm.nih.gov]
A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a urinary tract infection. [cdemcurriculum.com]
"Chapter 22: Pyelonephritis and other infections, reflux nephropathy, hydronephrosis, and nephrolithiasis". In Jennette, JC; Olson, JL; Schwartz, MM; et al. Heptinstall's Pathology of the Kidney. 2 (6th ed.). [en.wikipedia.org]
Serum
- Neutrophilia
Blood tests such as a complete blood count may show neutrophilia. [en.wikipedia.org]
Treatment
Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. [ncbi.nlm.nih.gov]
Prognosis
[…] long-standing infarcted ovary may have a more complex appearance with cystic or hemorrhagic degeneration Doppler findings in torsion are widely variable 3 little or no intra-ovarian venous flow (common) absent arterial flow (less common, sign of poor prognosis [radiopaedia.org]
Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J. Pediatr. Surg. 2009;44:868; author reply 868-9. Guthrie BD, Adler MD, Powell EC. [pemplaybook.org]
Although ovarian torsion in very young children is rare, a case of ovarian cyst torsion was reported in a 2-year-old. [17] Prognosis With early diagnosis and appropriate treatment, the prognosis of ovarian torsion is excellent. [emedicine.medscape.com]
Etiology
We report the successful management of a prenatally diagnosed ovarian cyst in a newborn female and provide operative evidence for the presumptive etiology of the cyst. [ncbi.nlm.nih.gov]
References: [1] [2] Ovarian torsion Etiology Physical activity (e.g., when exercising) The primary risk factor is ovarian enlargement (e.g., pregnancy, tumors, cysts). [amboss.com]
Epidemiology
The objective of this article is to present a case of pediatric ovarian torsion and to review its epidemiology, diagnosis, and treatment. A 3-year-old girl presented to the ED with vomiting, fever, anorexia, and abdominal pain. [ncbi.nlm.nih.gov]
Definition / general "Twisting" of fallopian tube that blocks blood flow, causing ischemia and associated edema and pain Often accompanies torsion of adjacent ovary (often with a cyst) but may be isolated to tube Epidemiology Occurs in women of all ages [pathologyoutlines.com]
Pathophysiology
The underlying pathophysiology involves torsion of the ovarian tissue on its pedicle leading to reduced venous return, stromal oedema, internal haemorrhage and infarction with the subsequent sequelae. [ncbi.nlm.nih.gov]
Epidemiology and Pathophysiology Ovarian torsion is the partial or complete twisting of an ovary around its ligamental support, often leading to an occlusion of its blood supply and associated with the sudden onset of abdominal pain and, if untreated, [pedclerk.bsd.uchicago.edu]
[…] of reproductive age, it can occur at any age. [2] Signs and symptoms [ edit ] Patients with ovarian torsion often present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting. [6] Pathophysiology [en.wikipedia.org]
Prevention
Oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a recurrent torsion. [ncbi.nlm.nih.gov]
The complete absence of flow should be confirmed by power Doppler to prevent erroneous interpretation. 3. In cases of partial/incomplete torsion, intra-ovarian flow may be demonstrated. [sonoworld.com]