Case Report
Volume 3 Issue 1 - 2016
Management of Adnexal Torsion in Extreme Ages
Bothinasaleem al-hegely1*
Department of Obstetrics and gynaecology, prince sultan armed forces hospital in al-medina, Saudi Arabia
*Corresponding Author: Bothinasaleem al-hegely, Department of Obstetrics and gynaecology, prince sultan armed forces hospital in al-medina, Saudi Arabia.
Received: February 08, 2016; Published: February 23, 2016
Citation: Bothinasaleem al-hegely. “Management of adnexal torsion in extreme ages”. EC Gynaecology 3.1 (2016): 220-222.
Abstract
Adnexal torsion is a rare gynecological emergency that requires an early surgical intervention to save the adnexa from irreversible damage .our study is about clinical presentation and management approach of adnexal torsion in a tertiary care Centre. We present 2 cases who present with adnexal torsion in extreme age, and deferential diagnosis, one of them 13 years old, the other one 75 years old, surgical laparoscope was the definitive line of diagnostic and therapeutic.
Keywords: Adnexal torsion; Laparoscope; Gynecological emergency; Ovarian cyst; Tumor markers; Ultrasound; Abdominal hysterectomy
Introduction
Ovarian torsion refers to the complete or partial rotation of the ovary on its ligamentous supports, often resulting in impedance of its blood supply. It is one of the most common gynecologic emergencies and may affect females of all ages [1]. When fallopian tube also twists with the ovary it is known as adnexal [2]. Prompt diagnosis is important to preserve ovarian and/or tubal function and to prevent other associated morbidity. However, making the diagnosis can be challenging because the symptoms are relatively nonspecific. Adnexal torsion mostly occurs in childbearing group, but is not uncommon in premenarchal girls or postmenopausal women [3].
It is important to note that torsion may occur in the presence of normal ovaries, particularly in the pediatric population [4]. As the symptoms are nonspecific it can lead to delay in diagnosing adnexal torsion. In a study of 179 patients, the clinical features of pelvic pain was found in 82%, nausea/vomiting in 49%, leukocytosis in 20.1%, fever in 7.8% and lower urinary symptoms in 14.5% [5].
Management
Laboratory investigations and imaging using Doppler scan, CT, MRI, helps in diagnosis. However surgical intervension, preferably by laparoscopy is the gold standard for diagnosis and treatment of adnexal torsion. The sensitivity of ultrasound in diagnosing torsion ranges from 40-75% [6]. In a study of 35 patients of adnexal torsion, correct diagnosis by clinical and sonography was only in 26% and with CT scan in 34% of cases [7]. Conservative surgery such as detorsion with cystectomy or cyst aspiration is preferred to removal of the adnexa when possible.
Case report 1
13y old girl came through emergency department complaining of right iliac fossa pain, pain associated with frequent vomiting Appendicitis was suspected, butpatient discharged to home. She came referred from private hospital with diagnosis of equerry right ovarian cyst /ovarian accident. The pain was dull aching ,no relieving or aggravating factors, she descript it as something pressing on her right lower abdomen ,no urinary symptoms ,pain was less severe than the presentation at first time. Gynecological history :menarche ,since one and half year ,regular cycle, last menstrual period was two weeks ago. No other significant past medical or surgical history. Vital sign was normal Abdomen examination: soft, with moderate right iliac fossa tenderness, no rebound tenderness.
Plan of management:
-ultrasound of abdomen & pelvis
-routine laboratory investigations
-possible CT scan of abdomen
-analgesics
-intravenous fluids
-to keep the patient fasting
Pelvic ultrasound reveals:
Right ovariancyst (5.2*5 cm) shows internal septation give appearance of hemorrhagic ovarian cyst.
-the left ovary was normal
-cul de sac: minimal nonspecific fluid seen
Laboratory investigations:
Platelet: 228
White blood cell: 8.2
Hemoglobin: 12.1
Kidney function test and liver function test: within normal range
ESR: within normal range
Tumor markers within normal range
Laparotomy was decided by her consultant and his team
Patient prepared to operation room
Preoperative diagnosis: right ovarian cyst
Post-operative diagnosis: torsion hemorrhagic right ovarian cyst
Operation: abdominal laparotomy with removal of the torsion hemorrhagic right ovarian cyst with right salpingo ophrectomy (right ovary and tubes severely congested and right ovary completely destroyed by hemorrhagic cyst and torsion
Left ovary and tubes looked normal.
Case report 2
75y old female patient referred from surgical department as surgical free.
She is p10+0
All her deliveries was normal spontaneous vaginal delivery
Menopausal more than 25y
No medical history of significance
Positive history of cholecystectomy
Her main complaint is lower abdominal pain with vomiting since 2 Days, the pain started lower abdominal then became more generalized, progressive, not responding to light analgesics. On examination, patient looks unwell, v/s stable.
Abdomen examination: no vein engorged or spider nevi seen, there is suprapubic tender mass extended to the right of midline below the umbilicus, nospleno or hepatomegaly. Pelvic ultrasound showed: right cystic lesion measuring about 16*10*12 cm most likely adnexal in origin.
Ct with Contract
Evidence of pear shaped complex lesion measuring about 17*10 cm elicits predominant cystic component with basal solid component is seen having intimate relation to the right ovary with oblique axis crossing the midline to the contralateral side .besides ,there is minimal free fluid seen at the right high adnexal region.
Laboratory investigation:
Liver function test: within normal range
Kidney function test: within normal range
PLT (Platlet) 224
Wbc (white blood cell count) 8.2
Hg: 12.1
Esr:-ve
Tumor markers: within normal range
Patient prepared for laparotomy
-under general anesthesia abdominal exploration by laparotomy revealed torsion congested hemorrhagic right adnexal mass included right ovary and right fallopian tube about 17*13 cm twisted twice extend from the right ovary upward to the diphram on the left side surrounded with hemorrhagic fluid
So, total abdominal hystrectomy done with bilateral salpingo ophrectomy and removal of right adnexal mass done Examination of lymph node done, not felt
Sample taken from greater omentom and send to histopath.
Conclusion
Diagnosis of ovarian torsion is a difficult task which requires good clinical awareness. High index of clinical suspicion is the most important factor in diagnosing adnexal torsion. Ultrasound with Doppler helps in diagnosing adnexal mass with torsion. Laparoscopy is not only useful for diagnosis but also for treating torsion with less morbidity. Conservative surgery is preferred for patients in the reproductive age group.
Bibliography
  1. McWilliams GD., et al. “Gynecologic emergencies”. Surgical Clinics of North America 88.2 (2008): 265-283.
  2. Growdon Whitfield B and Laufer Marc R. “Ovarian and fallopian tube torsion”. Up-to-date 4 (2013): 18.
  3. G Oelsnar and D Shashar. “Adnexal torsion”. Clinical Obstetrics and Gynecology 49.3 (2006): 459-463.
  4. SCHULTZ LR., et al. “Torsion of previously normal tube and ovary in children”. The New England Journal of Medicine: Research & Review 268 (1963): 268:343.
  5. LM Lo., et al. “Laparoscopy versus laparotomy surgical intervention of ovarian torsion”. Journal of Obstetrics and Gynaecology Research 34.6 (2008): 1020-1025.
  6. R Mashiach., et al. “Sonographic diagnosis of ovarian torsion:accuracy and predictive factors”. Journal of Ultrasound in Medicine 30.9 (2011): 1205-1210.
  7. Hiller Nurith., et al. “CT Features of Adnexal torsion”. American Journal of Roentgenology 189.1 (2007): 124-129.
Copyright: © 2016 Bothinasaleem al-hegely. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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