Dr. Serghei Puiu, Dr, PhD
Department of Radiology and Imaging, State University of Medicine and Pharmacy “Nicoale Testemitanu”, Chisinau, Republic of Moldova
Corresponding author: Serghei Puiu
Email: puiusv@yahoo.com
Clinical History:
A 47-year-old lady was referred to our department for a second opinion before surgery regarding an ovarian mass suspect of an ovarian tumour. She had an acute onset of severe pain in the lower right abdominal quadrant one week previously, which disappeared spontaneously. When she presented in our department, she had no pain or fever. Blood tests, including tumour markers, were normal.
Transabdominal and transvaginal ultrasound scans were performed. They showed an enlarged, but well-defined right ovary, appearing as a mass (Fig. 1-2). The stroma was heterogeneous due to edema displacing the follicles peripherally (Fig. 3). An echogenic thickened fallopian tube seemed to wrap the enlarged ovary (Fig. 4 a-c). The ovarian arterial and venous flow was preserved (Fig. 5 a-b). A small fluid collection in the Douglas pouch and around the ovary was seen. There was a slight pain on transducer touch.
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CORRECT ANSWER EXPLAINED BELOW | |
Correct answer is:Spontaneous complete detorsion of previously twisted ovary/adnexa
Explanation:We have shown a case of spontaneous detorsion of a previously twisted ovary. Ovarian or adnexal (ovary and fallopian tube) torsion is a surgical emergency that requires prompt diagnosis and treatment. It is defined as complete or partial rotation of the adnexa around the pedicle, causing lymphatic and venous ovarian congestion, followed by ischemia and necrosis due to arterial occlusion when untreated. It can rapidly progress to a stage of hemorrhagic necrosis in a few hours or remain at the stage of edema for several days, rarely resulting in complete spontaneous detorsion. Adnexal torsion accounts for approximately 3% of all gynecological emergencies [1]. The torsion may involve normal adnexa, however ovarian enlargement predisposes to torsion, commonly by corpus luteal cyst, benign ovarian tumour or ovulation induction [2, 3]. Prompt diagnosis is important to prevent irreversible damage of the ovary. However, the diagnosis can be challenging because clinical presentation of ovarian torsion is variable and often misleading. Definitive diagnosis is often achieved by surgery [4, 5]. Sonography is usually the first imaging tool used for evaluation, but the diagnostic accuracy is rather poor (46-74%) [6-9]. The sonographic findings vary from the enlarged ovary simulating a mass with peripherally displaced follicles in the early phase and a “solid” avascular appearance of the ovary in the late phase. However, Doppler is not a very sensitive for diagnosing ovarian torsion, and normal flow does not rule out torsion [10, 11]. An important sonographic sign of adnexal torsion is the “whirlpool sign”. A coiling pattern of ovarian vessels in the ovarian ligament refers to the sonographic appearance of the twisted ovarian vascular pedicle and has been shown to have up to 87% diagnostic accuracy for ovarian torsion [12-14]. In the rare cases of spontaneous complete detorsion the ultrasound findings can persist for a while after the untwisting because the edema does not disappear immediately [15]. In conclusion, the diagnosis of ovarian torsion remains challenging. In a patient who presents with acute pain and an ovary that demonstrates sonographic findings consistent with ovarian torsion, the diagnosis should be suggested even in the presence of documented arterial blood flow. References
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CORRECT ANSWER EXPLAINED BELOW | |
Correct answer is:Spontaneous complete detorsion of previously twisted ovary/adnexa
Explanation:We have shown a case of spontaneous detorsion of a previously twisted ovary. Ovarian or adnexal (ovary and fallopian tube) torsion is a surgical emergency that requires prompt diagnosis and treatment. It is defined as complete or partial rotation of the adnexa around the pedicle, causing lymphatic and venous ovarian congestion, followed by ischemia and necrosis due to arterial occlusion when untreated. It can rapidly progress to a stage of hemorrhagic necrosis in a few hours or remain at the stage of edema for several days, rarely resulting in complete spontaneous detorsion. Adnexal torsion accounts for approximately 3% of all gynecological emergencies [1]. The torsion may involve normal adnexa, however ovarian enlargement predisposes to torsion, commonly by corpus luteal cyst, benign ovarian tumour or ovulation induction [2, 3]. Prompt diagnosis is important to prevent irreversible damage of the ovary. However, the diagnosis can be challenging because clinical presentation of ovarian torsion is variable and often misleading. Definitive diagnosis is often achieved by surgery [4, 5]. Sonography is usually the first imaging tool used for evaluation, but the diagnostic accuracy is rather poor (46-74%) [6-9]. The sonographic findings vary from the enlarged ovary simulating a mass with peripherally displaced follicles in the early phase and a “solid” avascular appearance of the ovary in the late phase. However, Doppler is not a very sensitive for diagnosing ovarian torsion, and normal flow does not rule out torsion [10, 11]. An important sonographic sign of adnexal torsion is the “whirlpool sign”. A coiling pattern of ovarian vessels in the ovarian ligament refers to the sonographic appearance of the twisted ovarian vascular pedicle and has been shown to have up to 87% diagnostic accuracy for ovarian torsion [12-14]. In the rare cases of spontaneous complete detorsion the ultrasound findings can persist for a while after the untwisting because the edema does not disappear immediately [15]. In conclusion, the diagnosis of ovarian torsion remains challenging. In a patient who presents with acute pain and an ovary that demonstrates sonographic findings consistent with ovarian torsion, the diagnosis should be suggested even in the presence of documented arterial blood flow. References
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