The bottom line – there is no single finding that can definitively “rule in” or “rule out” ovarian torsion. She complains of persistent nausea and multiple episodes of vomiting. [Acute Pelvic pain in women-gynecological causes]. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. HHS Approximately 20% of the cases occur during pregnancy 1. Ovarian torsion can occur in all ages. Table 3 shows the accuracy of the various sonographic signs for diagnosis of ovarian torsion. Untreated ovarian torsion can result in complete loss of the ovary, as well as ovarian necrosis and infection. Interobserver agreement was excellent (Kappa=0.85). Symptoms typically include pelvic pain on one side. 2018 Feb;25(1):51-59. doi: 10.1007/s10140-017-1549-8. Treat pain and nausea with IV medications as soon as you have IV access – there is no need to wait for the diagnosis. While the overall incidence of ovarian torsion is low and there is almost no associated mortality, when missed, ovarian torsion can result in a significant degree of morbidity forRead More https://www.saem.org/.../m4-curriculum/group-m4-approach-to/ovarian-torsion Pelvic US for ovarian torsion was 80.0% sensitive (95% CI, 58.4-91.9%) and 95.0% specific (95% CI, 76.4-99.1%) for reader 1, while 80.0% sensitive (95% CI, 58.4-91.9%) and 85.0% specific (95% CI, 64.0-95.0%) for reader 2. Evaluate the sensitivity and specificity of pelvic ultrasound (US) and abdominopelvic computed tomography (CT) for the identification of ovarian torsion in women presenting to the emergency department with acute lower abdominal or pelvic pain. PURPOSE: Ovarian torsion (OT) is a true surgical emergency that requires prompt diagnosis and therapy. Her last normal menstrual period ended two-weeks ago. The most dangerous condition in the differential for adnexal torsion is an ectopic pregnancy, and as such, a pregnancy test should be ordered to help screen for it. Phone: 847.813.9823 Image 2. The varied imaging features and nonspecific symptoms of ovarian torsion can lead to a delay in identification, with misdiagnosis being common. Pearls and pitfalls in diagnosis of ovarian torsion. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Diagnostic evaluation of ovarian torsion: An analysis of pediatric patients using the Nationwide Emergency Department Sample. 2020 Feb;30(2):1054-1061. doi: 10.1007/s00330-019-06434-y. Purulent cervical discharge and cervical motion tenderness point towards PID with a tubo-ovarian abscess. Search Strategy: Your friendly neighborhood medical librarian (Susan Fowler, MLIS fowler@wustl.edu) provides you with the following search strategy (summarized at http://tinyurl.com/245dp8e). Epub 2018 Feb 17. The respective sensitivity, specificity, and accuracy of a twisted pedicle for the diagnosis of ovarian torsion were 73%, 88%, and 78%, respectively for reader 1 and 73%, 100%, and 83%, respectively for reader 2. Physical examination may reveal pelvic or lower abdominal tenderness. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. Image 1. NIH Image from  EMLyceum https://emlyceum.com/2012/06/21/ovarian-torsion-answers/ Used by Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence (http://creativecommons.org/licenses/by-nc-sa/3.0/) (CC Licence). Women with pathologically low flow are more likely to have torsion. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Cureus.  |  Radiologe. As the premier organization for high-quality research and educational innovation in emergency care, the Society for Academic Emergency Medicine (SAEM) creates and promotes scientific discovery, advancement of education, and the highest professional and ethical standards for clinicians, educators, and researchers. However, heightened awareness and suspicion of this condition are needed for timely intervention. The right ovary has no Doppler flow while the left maintains flow. The risk goes down when the size of the ovary becomes more massive (> 20.0 cm) due to decreased motility. Lack of ovarian blood flow on doppler sonography seems to be a good predictor of ovarian torsion. Successful Oocyte Retrieval After Follicular Fluid Aspiration in Suspicious of Ovarian Torsion. It will also evaluate for the presence of concurrent infection. Left maintains normal flow. Lourenco AP, Swenson D, Tubbs RJ, Lazarus E. Emerg Radiol. Look for corroborating evidence on pelvic exam: adnexal tenderness on the same side as the pain and, less commonly, an adnexal mass. Ovarian torsion: 10-year perspective. US) that delays therapy is unlikely to improve preoperative diagnostic yield. Right Lower Quadrant Abdominal Pain: Do Not Forget About Ovarian Torsion on the Computed Tomography Scan. 2014 Apr;21(2):179-87. doi: 10.1007/s10140-013-1163-3. The cause of this twisting can be multifactorial. Establishing IV access and administering antiemetics and pain medication may aid in evaluation of the patient. USA.gov. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. The classic presentation of adnexal torsion is sudden onset of unilateral lower abdominal pain which is often described as a stabbing pain and is commonly accompanied by nausea and vomiting. 2020 Mar;60(3):216-225. doi: 10.1007/s00117-019-00618-9. 2014 Nov;203(5):W470-81. Used by Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence (http://creativecommons.org/licenses/by-nc-sa/3.0/) (CC Licence). While classically the pain is sudden in onset, this is not always the case. Presence of ovarian cysts was significantly associated with torsion. O… Fax: 847.813.5450. Absence of Doppler flow has high specificity but low sensitivity. The ovary, and often the fallopian tube (adnexal torsion), become twisted around their vascular pedicle. For US studies, the radiologists graded the adnexal Doppler waveforms as either normal or suspicious for torsion. Radiopedia Case Ovarian Torsion https://radiopaedia.org/cases/ovarian-torsion-10?lang=us. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 The sensitivity and specificity of CT for ovarian torsion was 100.0% and 85.0% respectively for reader 1, and 90.0% and 90.0% for reader 2. In reproductive age females the increase in ovarian size is most commonly due to follicular cysts or corpus luteum cysts. Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging. The remainder of findings on ultrasound and CT are nonspecific. Diagnostic testing is essential when evaluating a patient with suspected ovarian torsion. doi: 10.7759/cureus.12192. Ovarian torsion (OT) is when an ovary twists on its attachment to other structures, such that blood flow is decreased. The ovary has a dual blood supply (ovarian artery and uterine artery) so even if the supply is cut off to one there still may be Doppler blood flow to the ovary. In this study, we have adopted a case-based statistical analysis to identify important sonographic markers and further evaluated their contribution in identifying ovarian to… The cyst was decompressed and the pedicle of the right ovary was detorsed causing return of blood flow. COVID-19 is an emerging, rapidly evolving situation. In this article, we discuss and illustrate the normal appearance and arterial flow … Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly. The diagnosis of ovarian torsion is made definitively in the operating room. In addition we aim to describe patterns in the clinical presentation of the disease. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. Although ultrasound is the ideal non-invasive first-line technique, … It is less common with malignant masses, likely due to adhesions. The pain may radiate to the groin. Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. Career Development and Mentorship Committee, Communications and Social Media Committee, Effective Consultation in Emergency Medicine Video, Residency Match in the Era of COVID: Advice for Medical Educators in Emergency Medicine, SAEMF/CDEM Innovations in Undergraduate Emergency Medicine Education Grant, The Power of Mentorship: Pearls and Pitfalls in Medical Education Research, Clerkship Coordinator’s Handbook Clerkship Coordinator’s Handbook, Virtual Rotation and Educational Resources, Diversity, Equity, and Inclusion (DEI) Library, https://radiopaedia.org/cases/ovarian-torsion-10?lang=us, http://creativecommons.org/licenses/by-nc-sa/3.0/, https://emlyceum.com/2012/06/21/ovarian-torsion-answers/, Pain may be reminiscent of a kidney stone: colicky, fairly sudden onset, radiation to the groin. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. Torsion occurs due to two main reasons 2: 1. hypermobility of the ovary: <50% 2. adnexal mass: ~50-80% 2.1. most lesions are dermoid cysts or paraovarian cysts 2.2. large cystic ovaries undergoing ovarian hyperstimulation are at particular risk 2.3. masses between 5-10 cm are at most risk 13 The initial twisting causes obstruction of venous return. CT may, however, be helpful ruling in or ruling out appendicitis or kidney stone as an alternate diagnosis. Eur J Radiol. Typically CT images demonstrate fat (areas with very low Hounsfield values), fat fluid level, calcification (sometimes … “Time is ovary,” to borrow a phrase, so consult your gynecologist early. Both CT and US seem like reasonable tests to identify the presence of underlying ovarian pathology. While it can rarely occur with a normal ovary, the majority of cases are associated with some type of ovarian pathology (e.g., tumor, cyst, hyperstimulation syndrome secondary to infertility treatments). However, either ultrasound or CT may help you find other pathology to explain a patient’s pain (eg, kidney stone, appendicitis). J Ultrasound Med 2008; 27: 7-13. Right ovary without Doppler flow suggesting ovarian torsion. Emergency GYN consult is required in all suspected ovarian torsion cases. The surrounding fallopian tube was dusky and ischemic appearing. The absence of blood flow within the ovary on Doppler exam is a highly specific finding but the presence of Doppler flow does not exclude the diagnosis of torsion. Amidst an increasingly busy winter flu season, you encounter a 25 year old female with acute onset abdominal pain. Two radiologists who were blinded to clinical data interpreted all studies as (1) demonstrating an abnormal ovary or not, and (2) suggestive of torsion or not. Bridwell, Rachel. Most surgeons will try to salvage any normal ovarian tissue in a premenopausal patient. 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