SPR Unknown # 59 -- FINAL

Marina Doliner, M.D.

St Francis Hospital

mdoliner@comcast.net

Martha Saker, MD

Children's Memorial Hospital Chicago

Keywords

1678, ovarian torsion


Publication Date: 2010-12-20

History

10 year old female with history of suprapubic abdominal pain x 1 day.

Findings

CT abdomen/pelvis: Main findings: 5.3 x 9.8 x 5.2 cm heterogeneous mass with peripheral cystic areas, within the midportion of the pelvis between bladder and rectum.

Diagnosis

Torsed L Ovary with periovarian/peritunal hematoma/hemorrhagic cyst.

Next day , in OR: normal uterus, and R ovary. No nml L ovary. Purple pelvic mass consistent with torsed ovary and hematoma/hemorrhagic peritubal/periovarian cyst. Dusky adnexa un-twisted with improvement of color/perfusion. Bx: ischemic ovarian tissue. US 9 days post-op: Normal uterus & ovaries with arterial and venous flow, better seen on the right than the left.

DDx

DDX PID, appendicitis, endometriosis, distal uriteral calculus, pregnancy (particularly ectopic), ovarian tumor. Other masses including complex ovarian cyst, evolving hematoma may be considered. Other pelvic masses include tubovarian abscess, ovarian tumors, and complex appendicitis. Lymphoma and rhabdomyosarcoma are common pelvic tumors in children. Differential diagnosis is made by clearly identifying vascularized ovaries or ovarian tissue bilaterally.

Discussion

In pediatric patients, torsion of a normal ovary is more common than in adults and more common than torsion of an ovarian cyst or tumor. Typical age is 10-11 years of age, half of cases in premenarchal girls. Asynchronous bilateral torsion occurs in 5-10%. Because of its rarity and nonspecific presentation, the diagnosis is usually delayed. Symptoms include lower abdominal pain, nausea, vomiting, and low-grade fever. A palpable mass is found in two-thirds of patients. The sonographic findings of torsion vary. Adnexal cyst or tumor may be present. The involved ovary is edemous and hemorrhagic, causing sonographic enlargement and increased echogenicity. Peripheral follicular distention due to transudation of fluid is seen. The twisted, engorged, edematous ovary will be seen as a hypo- or hyper-echoic mass with good sound transmission and absent color doppler flow. Classically, the diagnosis of ovarian torsion is made by ultrasound and doppler, although if an enlarged ovary is seen by CT in a patient with abdominal pain, torsion should be considered. Urgent surgical intervention is needed.

Typical findings: Unilaterally enlarged (7-200cc, average 24cc)edematous appearing ovary with prominent > 8-12mm peripheral follicles. The fallopian tube is typically enlarged >10mm and may contain simple fluid or blood, associated with free fluid. Hematoma, cyst, tumor may be seen. Uterus is typically deviated to the side of the torsed adnexa, lack of tissue enhancement of ovarian stroma, +/- thickened walls of fallopian tube. Heterogeneous echotexture on US, A whirlpool sign of twisted vascular ovarian pedicle may be seen and is a definitive sign of torsion. Presence of arterial and venous flow in the ovary on doppler examination does not exclude torsion. However normal appearance of the ovary on both grey scale and Doppler US makes torsion highly unlikely.

References

  1. Adnexal torsion: magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance. J Magn Reson Imaging. 2004 Sep;20(3):451-62. Ghossain MA, Hachem K, Buy JN, Hourany-Rizk RG, Aoun NJ, Haddad-Zebouni S, Mansour F, Attieh E, Abboud J.
  2. CT and MR imaging features of adnexal torsion. Radiographics. 2002 Mar-Apr;22(2):283-94. Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS, Kim H, Lee JM.
  3. Adnexal mass with pelvic pain. Radiol Clin North Am. 2004 Mar;42(2):329-48.Webb EM, Green GE, Scoutt LM.
  4. Pediatric gynecologic ultrasound. Ultrasound Q. 2004 Sep;20(3):127-39.Ratani RS, Cohen HL, Fiore E.
  5. Sonographic whirlpool sign in ovarian torsion.J Ultrasound Med. 2004 Dec;23(12):1643-9; quiz 1650-1. Vijayaraghavan SB
  6. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005 Jun;159(6):532-5. Anders JF, Powell EC.
  7. Kirks, D.R., Griscom, N.T., PRACTICAL PEDIATRIC IMAGING: Diagnostic Radiology of Infants and Children, Lippincott-Raven Publishers, 1998, 1143-1144.
  8. StatDx

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