Computed tomography; Emergency department; Ovarian torsion; Ultrasound. 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. Most surgeons will try to salvage any normal ovarian tissue in a premenopausal patient. There are no laboratory tests to establish the diagnosis of adnexal torsion. The objective of this thesis is to determine the trends in usage of CT scanning and its sensitivity during the workup of pelvic pain and suspected torsion. Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. “Ovarian Torsion.” UpToDate, 10 Apr. [Acute Pelvic pain in women-gynecological causes]. Treatment of adnexal torsion is surgical. 2018 Aug;55(2):e43-e45. The diagnosis of ovarian torsion is made definitively in the operating room. The cause of this twisting can be multifactorial. The risk goes down when the size of the ovary becomes more massive (> 20.0 cm) due to decreased motility. Predicting necrosis in adnexal torsion in women of reproductive age using magnetic resonance imaging. Phone: 847.813.9823 There are conflicting reports on the accuracy of different imaging modalities for OT. In addition we aim to describe patterns in the clinical presentation of the disease. Successful Oocyte Retrieval After Follicular Fluid Aspiration in Suspicious of Ovarian Torsion. 2014 Apr;21(2):179-87. doi: 10.1007/s10140-013-1163-3. Radiologe. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. [7] USA.gov. 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). 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. Pearls and pitfalls in diagnosis of ovarian torsion. Interobserver agreement was excellent (Kappa=0.85). Epub 2017 Sep 7. Pelvic or intravaginal ultrasound remains the first-line imaging modality used for diagnosis and evaluation of suspected ovarian/adnexal torsion. Physical examination may reveal pelvic or lower abdominal tenderness. The cyst was decompressed and the pedicle of the right ovary was detorsed causing return of blood flow. The bottom line – there is no single finding that can definitively “rule in” or “rule out” ovarian torsion. Left maintains normal flow. Ovarian torsion does occur in normal ovaries. 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. 1111 East Touhy Ave, Suite 540 2019 Feb;59(2):126-132. doi: 10.1007/s00117-018-0475-4. 2020 Mar;60(3):216-225. doi: 10.1007/s00117-019-00618-9. A pelvic exam demonstrates right adnexal fullness and significant pain on exam without bleeding or discharge. On pelvic exam, the patient may have adnexal tenderness or an adnexal mass. In this article, we discuss and illustrate the normal appearance and arterial flow … The patient was closed and taken to recovery where she had resolution of her symptoms. Materials and methods: Emerg Med Australas. Treat pain and nausea with IV medications as soon as you have IV access – there is no need to wait for the diagnosis. Reader 1 had no CT false negatives. Early recognition and restoration of blood flow are important to avoid irreversible ovarian damage. It is less common with malignant masses, likely due to adhesions. The most common ultrasound finding in torsion is enlargement or edema of the ovary. 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. This is a retrospective study of 20 cases of ovarian torsion and 20 control patients, all of whom had both US and CT performed in the emergency department. Rush Medical College, Originally Written By: Lynne Yancey University of Colorado School of Medicine. [12] A prospective study of 199 patients showed doppler ultrasound has a sensitivity and specificity for torsion of 100 and 97%. Conclusion: Epub 2016 Nov 17. Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. This site needs JavaScript to work properly. 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 White M, Stella J. Its use results in decreased time to diagnosis. Results: Sixty-one percent of right ovarian torsion case and 27% of left ovarian torsion cases had normal Doppler flow. 2020 Dec 20;12(12):e12192. Absence of Doppler blood flow is a helpful finding (high specificity), but this finding has a low sensitivity for detecting torsion. Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X, De Laveaucoupet J. Emerg Radiol. doi: 10.2214/AJR.13.12279. 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. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. 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/. Epub 2018 Feb 17. She has no past medical or surgical history (including no STD’s) and she has never been pregnant. Bridwell, Rachel. Ovarian torsion is a gynecological emergency and is caused by the twisting of the ovary and fallopian tube on the vascular pedicle. It will also evaluate for the presence of concurrent infection. However, either ultrasound or CT may help you find other pathology to explain a patient’s pain (eg, kidney stone, appendicitis). There is a significant diagnostic delay at 101.8 hours (median). Since clinical presentation may be nonspecific and physical findings are often inconclusive, imaging is required for a timely and accurate diagnosis. Pregnancy also results in an increased risk of torsion due to an enlarged corpus luteum. The Clerkship Directors in Emergency Medicine (CDEM) is an Academy of SAEM. Interobserver agreement was excellent (Kappa=0.85). Consult gynecology early if you have a high suspicion for torsion. It is important to remember that approximately 40% of patients will report gradual pain instead of the acute onset pain that is frequently associated with torsion and some patients may describe back or flank pain. Ovarian torsion represents a true gynecological emergency and requires rapid evaluation and management in order to salvage the ovary. Objective: As they predispose to ovarian torsion [2], they may present with acute pelvic pain. Flow is normal in 54% to 60% of cases. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Ovarian and tubal torsion: imaging findings on US, CT, and MRI. doi: 10.1016/j.jemermed.2018.01.006. High clinical suspicion, even if tests are negative, necessitates consultation with obstetricians for possible OR management. Des Plaines, IL 60018 National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Diagnostic evaluation of ovarian torsion: An analysis of pediatric patients using the Nationwide Emergency Department Sample. Emergency GYN consult is required in all suspected ovarian torsion cases. Radiographics. The tube is dusky and engorged with engorgment of the ovary. Swenson D et al. Amidst an increasingly busy winter flu season, you encounter a 25 year old female with acute onset abdominal pain. The bedside ultrasound was inconclusive. The best initial imaging for ovarian torsion is a transvaginal ultrasound with Doppler. To investigate adnexal torsion, ultrasound is a good first‐line diagnostic test with a pooled sensitivity of 0.79 and specificity of 0.76. What every radiologist should know about adnexal torsion. 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. The right ovary has no Doppler flow while the left maintains flow. 2005; 17(3):231-7. MRI findings are similar to those on CT, but  MRI is not commonly ordered from the ED. As with any emergency department patient, start with a primary assessment: airway, breathing, circulation.  |  Ovarian torsion: 10-year perspective. Reichelt A, Meinel FG, Wirth S, Weber MA, Bath K. Radiologe. Ovarian torsion has a bimodal age distribution occurring mainly in young women (15-30 years) and post-menopausal women. COPYRIGHT © 2021 SAEM, ALL RIGHTS RESERVED. J Emerg Med. J Ultrasound Med 2008; 27: 7-13. The surrounding fallopian tube was dusky and ischemic appearing. 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. The diagnostic performance of CT is not shown to be significantly different from that of US in identifying ovarian torsion in this study. A urinalysis may reveal blood consistent with nephrolithiasis, or it may show nitrites and leukocyte esterase more consistent with a urinary tract infection. NLM Ovarian/adnexal torsion is a rather frequent occurrence in women of reproductive age group worldwide. 2020 Feb;30(2):1054-1061. doi: 10.1007/s00330-019-06434-y. The remainder of findings on ultrasound and CT are nonspecific. 2014; 83(4):733-8. Sensitivity and specificity were respectively 42.9% and 81.8% for B-Mode ultrasound and 100% and 81.8% for contrastenhanced ultrasonography. Absence of Doppler flow has high specificity but low sensitivity. Am J Surg. On exam she is clearly in distress, clutching her right lower abdomen. Image 1 demonstrates a side by side comparison. 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. Lack of ovarian blood flow on doppler sonography seems to be a good predictor of ovarian torsion. Ultrasound has a sensitivity for ovarian torsion of 79% and computerized tomographic scan of 42.2%. A 25 year-old female presents to the ED with a chief complaint of RLQ abdominal pain. Leukocyte esterase more consistent with a tubo-ovarian abscess ( TOA ): e12192 on the vascular pedicle imaging for torsion. 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