USA.gov. The diagnosis of ovarian torsion is made definitively in the operating room. Rush Medical College, Originally Written By: Lynne Yancey University of Colorado School of Medicine. A 25 year-old female presents to the ED with a chief complaint of RLQ abdominal pain. The risk goes down when the size of the ovary becomes more massive (> 20.0 cm) due to decreased motility. Children have a higher incidence of torsion of a normal ovary than in the adult population. There are no laboratory tests to establish the diagnosis of adnexal torsion. 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 Other symptoms may include nausea. Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X, De Laveaucoupet J. Emerg Radiol. Clipboard, Search History, and several other advanced features are temporarily unavailable. Commonly an ovarian mass or cyst can be visualized and in, later stages, free pelvic fluid (indicating hemorrhage) can be seen. AJR Am J Roentgenol. Physical exam should include an abdominal exam and a pelvic exam, including a bimanual exam, to assess for adnexal tenderness and fullness that may be present. 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. Emergency GYN consult is required in all suspected ovarian torsion cases. The ovary must be untwisted as soon as possible to restore blood flow. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. 2014 Apr;21(2):179-87. doi: 10.1007/s10140-013-1163-3. This leads to vascular congestion, which causes engorgement and edema. Abdominopelvic CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9-100.0%) and 85.0% specific (95% CI, 64.0-94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9-97.2%) and 90.0% specific (95% CI, 69.9-97.2%) for reader 2. Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging. A positive pregnancy test does not eliminate the diagnosis of ovarian torsion, especially early in pregnancy, as a corpus luteum cyst may be the source of torsion. Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. In my mind in a patient with undifferentiated abdominal pain and structurally normal ovaries I'm not sure that routinely adding an ultrasound would help us identify these extremely rare cases of torsion. Des Plaines, IL 60018 She complains of persistent nausea and multiple episodes of vomiting. Computed tomography; Emergency department; Ovarian torsion; Ultrasound. A CT in an adult female that shows normal sized and appearing ovaries likely excludes the diagnosis of torsion. Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. Ovarian torsion (OT) is when an ovary twists on its attachment to other structures, such that blood flow is decreased. Acute gynaecologic disorders are commonly encountered in daily clinical practice of emergency departments (ED) and predominantly occur in reproductive-age women. Both CT and US seem like reasonable tests to identify the presence of underlying ovarian pathology. Point of Care urine pregnancy test and urinalysis were negative. The most common ultrasound finding in torsion is enlargement or edema of the ovary. CT in ovarian torsion is nonspecific, with the most common finding being an enlarged ovary or ovarian mass. The bedside ultrasound was inconclusive. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. [12] A prospective study of 199 patients showed doppler ultrasound has a sensitivity and specificity for torsion of 100 and 97%. doi: 10.1016/j.jemermed.2018.01.006. Right ovary without Doppler flow suggesting ovarian torsion. The greatest percentage of cases occur in the reproductive years but torsion also occurs in children and post-menopausal females. 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. Objective: 2019. CT may as sensitive as US. Lourenco AP, Swenson D, Tubbs RJ, Lazarus E. Emerg Radiol. 2018 Feb;25(1):51-59. doi: 10.1007/s10140-017-1549-8. Interobserver agreement was excellent (Kappa = 0.85). The remainder of findings on ultrasound and CT are nonspecific. Lack of ovarian blood flow on doppler sonography seems to be a good predictor of ovarian torsion. Torsion does occur in infants, children, and postmenopausal women. Shadinger LL, Andreotti RF, Kurian RL. In this study, we performed a meta-analysis of all the published studies on B-mode ultrasound (US, morphological criteria), Doppler US (DUS, flow criteria), and computed tomography (CT) for the diagnosis of OT. [13] For Tubo-Ovarian Abscess (TOA): Sensitivity, specificity and interobserver variation were calculated for each imaging modality. We compared the CT and MR imaging findings in adnexal torsion in patients with versus those without hemorrhagic infarction in terms of the presence of tube thickening, size of the twisted ovarian mass, wall thickness of the twisted ovarian mass, and presence of ascites and uterine deviation using the Student t test and the Fisher exact two-tailed test. Presence of ovarian cysts was significantly associated with torsion. Approximately 20% of the cases occur during pregnancy 1. Ovarian torsion should also be considered in infants and small children with feeding intolerance, abdominal distension, vomiting, irritability, and/or a palpable pelvic mass. Keep the patient NPO in preparation for the OR. 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… CT may, however, be helpful ruling in or ruling out appendicitis or kidney stone as an alternate diagnosis. However, either ultrasound or CT may help you find other pathology to explain a patient’s pain (eg, kidney stone, appendicitis). She has no past medical history, is a social alcohol drinker, and does not use tobacco products. 2020 Mar;60(3):216-225. doi: 10.1007/s00117-019-00618-9. [Sudden chest pain and lower abdominal pain : The usual suspects]. The diagnosis is challenging to make accurately and quickly, relying on a combination of physical exam, history and radiologic evaluation. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. The pain may radiate to the groin. Epub 2017 Sep 7. Some studies have shown as high as 60% of cases of surgically verified ovarian torsion will have arterial blood flow on ultrasound. As with any emergency department patient, start with a primary assessment: airway, breathing, circulation. 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). A consultative transvaginal ultrasound was obtained which demonstrated a decreased Doppler flow to the right ovary. CT. good at ruling out ovarian torsion if a normal ovary/adnexa is seen on ultrasound; the twisted ovarian pedicle is pathognomonic for ovarian torsion if demonstrated 11 Etiologies are quite diverse with ovarian lesions and corpus luteal cysts being the most two common. For ovarian torsion: A retrospective study of 834 patients showed the NPV of a contrast enhanced CT of the pelvis for ovarian torsion is 100%. If, on surgical examination, the ovarian tissue is obviously necrotic, there is a mass concerning for malignancy, or the patient is postmenopausal, then a salpingo-oophorectomy will likely be performed. Successful Oocyte Retrieval After Follicular Fluid Aspiration in Suspicious of Ovarian Torsion. A bedside transabdominal ultrasound was obtained to evaluate for possible free abdominal/pelvic fluid. A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a urinary tract infection. The bottom line – there is no single finding that can definitively “rule in” or “rule out” ovarian torsion. She is mildly tachycardic with intact distal pulses and has clear equal breath sounds. Results: Sensitivity of ultrasound was 70% and specificity was 87%. Interobserver agreement for pelvic US was fair (Kappa=0.60). Images courtesy of Dr. Maulik S Patel. NLM What every radiologist should know about adnexal torsion. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. The patient was closed and taken to recovery where she had resolution of her symptoms. 2019 Feb;59(2):126-132. doi: 10.1007/s00117-018-0475-4. Even if a dusky, edematous ovary is discovered in the OR, there is often functional recovery if the tissue is not necrotic. Ultrasound has a sensitivity of approaching 100% and specificity of 97% if there is an enlarged ovary with an absence of arterial and venous blood flow 14. However, heightened awareness and suspicion of this condition are needed for timely intervention. Ovarian torsion does occur in normal ovaries. Gynecology was emergently consulted who recommended proceeding to the OR for laparoscopy. Table 3 shows the accuracy of the various sonographic signs for diagnosis of ovarian torsion. Radiopedia Case Ovarian Torsion https://radiopaedia.org/cases/ovarian-torsion-10?lang=us. [7] Positive Doppler flow to the ovary does not rule out torsion. Reader 1 had no CT false negatives. Her abdomen exhibits tenderness and guarding to the right lower quadrant, normal bowel sounds and no organomegaly. Cureus. PURPOSE: Ovarian torsion (OT) is a true surgical emergency that requires prompt diagnosis and therapy. 2018 Aug;55(2):e43-e45. White M, Stella J. 2005; 17(3):231-7. Any female patient who presents with abdominal pain should prompt consideration of torsion in ED providers. Peritoneal signs are concerning for ovarian necrosis. Consult gynecology early if you have a high suspicion for torsion. Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Flow is normal in 54% to 60% of cases. Radiographics. RadioGraphics 2008; 28: 1355-1368. “Ovarian Torsion.” UpToDate, 10 Apr. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. 2020 Feb;30(2):1054-1061. doi: 10.1007/s00330-019-06434-y. Vital signs reveal BP 145/90, HR 110, RR 21, Tmax 98.9 SpO2 99%RA. 2008 Sep-Oct;28(5):1355-68. doi: 10.1148/rg.285075130. 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. Approximately 20% of the cases occur during pregnancy 1. 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. Other signs on CT include asymmetric adnexal enhancement, thickened fallopian tube, associated free fluid/hemorrhage, and deviation of the uterus to the affected side. She is slightly obese but is otherwise well-appearing. Most surgeons will try to salvage any normal ovarian tissue in a premenopausal patient. Women with pathologically low flow are more likely to have torsion. J Ultrasound Med 2008; 27: 7-13. The surrounding fallopian tube was dusky and ischemic appearing. [Acute Pelvic pain in women-gynecological causes]. Physical examination may reveal pelvic or lower abdominal tenderness. Treat pain and nausea with IV medications as soon as you have IV access – there is no need to wait for the diagnosis. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. Materials and methods This retrospective, single-institution case-control study included 43 women with adnexal torsion and 43 age- and ovarian mass-matched control women. Phone: 847.813.9823 Swenson D et al. The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. The cyst was decompressed and the pedicle of the right ovary was detorsed causing return of blood flow. Purulent cervical discharge and cervical motion tenderness point towards PID with a tubo-ovarian abscess. CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9–100.0%) and 85.0% specific (95% CI, 64.0–94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9–97.2%) and 90.0% specific (95% CI, 69.9–97.2%) for reader 2. MRI findings are similar to those on CT, but  MRI is not commonly ordered from the ED. Pelvic US was interpreted as demonstrating an abnormal ovary in 90.0% of ovarian torsion cases by reader 1, and in 100.0% by reader 2, whereas CT was interpreted as revealing an abnormal ovary in 100.0% of torsion cases by both readers. NIH Abdominopelvic CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9–100.0%) and 85.0% specific (95% CI, 64.0–94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9–97.2%) and 90.0% specific (95% CI, 69.9–97.2%) for reader 2. 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/. Radiologe. Left maintains normal flow. Interobserver agreement was excellent (Kappa=0.85). Its use results in decreased time to diagnosis. Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. 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. Emerg Med Australas. Bridwell, Rachel. It is less common with malignant masses, likely due to adhesions. “Time is ovary,” to borrow a phrase, so consult your gynecologist early. The greatest risk factor for ovarian torsion is ovarian enlargement, typically caused by an ovarian cyst or mass. This site needs JavaScript to work properly. On exam she is clearly in distress, clutching her right lower abdomen. PMID: 24480106. There are conflicting reports on the accuracy of different imaging modalities for OT. Sensitivity and specificity were respectively 42.9% and 81.8% for B-Mode ultrasound and 100% and 81.8% for contrastenhanced ultrasonography. Get an ultrasound to look for Doppler flow. Am J Surg. The incidence of torsion in patients with structurally normal seems to be extremely low. 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. CT images were evaluated independently by two readers for the … Amidst an increasingly busy winter flu season, you encounter a 25 year old female with acute onset abdominal pain. Ovarian torsion can occur in all ages. J Emerg Med. Interobserver agreement was excellent (Kappa=0.85). Keywords: She tells the triage nurse that she has had intermittent episodes of the pain but over the past 45 minutes the pain has become unbearable and excruciating. A history of prior ovarian cyst or mass, prior ovarian torsion, or current pregnancy should increase your suspicion for torsion. In this article, we discuss and illustrate the normal appearance and arterial flow … Interobserver agreement was excellent (Kappa=0.85). For US studies, the radiologists graded the adnexal Doppler waveforms as either normal or suspicious for torsion. The tube is dusky and engorged with engorgment of the ovary. 2014; 83(4):733-8. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. The sensitivity of the individual signs ranged from 36.2% to 85.1%, … Eur J Radiol. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. 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