Case Reports

Diagnosis of ovarian torsion in a hemodynamically unstable pediatric patient by bedside ultrasound in the ED

A 15-year old gravida 1 para 1 Hispanic girl presented to the ED for the third time in 3 days with persistent lower abdominal, back pain, and dysuria of 4 days’ duration. On her 2 prior visits, she had been discharged home with a diagnosis of large left ovarian cyst, prescribed pain medication, and given a follow-up gynecology clinic appointment. During this visit, the patient reported that her pain was increasing, and she had only partial relief with hydrocodone and ibuprofen. She denied fever, chills, nausea, vomiting, diarrhea, or constipation. Her last menstrual period was 1.5 weeks prior, and her last Papanicolaou smear was 6 months ago with no abnormal- ities. She reported that her menstrual periods were regular and denied any Sexually transmitted diseases. Five months before presentation, the patient had a cesarean section at term without complications.

On physical examination, she was tachycardiac (heart rate, 135 beats per minute), hypotensive (blood pressure, 98/ 45 mm Hg), and febrile (temperature, 38.78C) with exquisite tenderness to palpation in the lower abdominal and supra- pubic regions accompanied by diffuse guarding and rebound. She had no organomegaly or costovertebral angle tenderness. Approximately 4 hours after arrival, her hemoglobin dropped from 11.8 g/dL on arrival to 9.8 g/dL. The attending emergency physician detected an 7 x 9 cm multiloculated left adnexal mass suggestive of an ovarian cyst on Transabdominal ultrasound (Fig. 1). Using endovaginal ultrasound, there was no evidence of arterial waveform despite multiple samples of spectral wave Doppler (Figs. 2 and 3). The diagnosis of an ovarian torsion was made, and emergent gynecology consultation was obtained. The patient was expedited to the operating room for Exploratory laparotomy and left salpingo-oophorectomy. Surgical find- ings were (1) an 8-cm necrotic left ovary with approximately

3 revolutions noted at its base, (2) a 12-cm necrotic hematosalpinx, and (3) a normal-appearing right ovary, tube, and uterus. Surgical pathology findings of the left ovary and fallopian tube correlated with torsion of the ovarian cyst.

The diagnosis of ovarian torsion is challenging. Clinical symptoms are nonspecific, making imaging studies critical. Ultrasound is the imaging modality of choice and can lead to a rapid diagnosis resulting in prompt surgical inter- vention [1]. It is clearly advantageous to perform an

immediate bedside ultrasound on unstable patients rather than send them out of the department for time-consuming radiological studies. In a patient such as ours, in addition to prompt resuscitation, an important goal is to expedite surgical management in an attempt to salvage the torsed ovary and adnexa.

Gray-scale ultrasound is useful for identifying adnexal masses, ovarian size, and position. The most consistent finding in patients with ovarian torsion on ultrasound is ovarian enlargement, secondary to reduced or absent venous and lymphatic circulation with continued arterial flow to the ovary. Identification of ovarian pathology is important because ovarian cysts and neoplasms are associated with the higher risk of ovarian torsion [2]. These adnexal masses can act as a fulcrum promoting adnexal or ovarian rotation. Doppler ultrasound provides useful information regard- ing ovarian vascularity and blood flow. Numerous studies have shown that reduced or absent blood flow found by Doppler correlates significantly with ovarian torsion [3,4]. However, normal blood flow through the ovary does not exclude the diagnosis of ovarian torsion. Pena et al [4] found that abnormal Doppler results predicted a preopera- tive diagnosis of ovarian torsion in 100% of their cases, whereas normal Doppler results excluded the diagnosis in only two thirds of cases. In addition, the authors found that abnormal Doppler findings have been proven to reduce time to diagnosis (59 vs 5.3 hours) and time to hospital discharge

Fig. 1 A left cystic structure, 7 x 9 cm, demonstrated on bedside transabdominal ultrasound.

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Fig. 2 No evidence of arterial spectral Doppler waveforms on left ovarian tissue on bedside endovaginal ultrasound.

Fig. 3 Normal-appearing arterial spectral Doppler waveform on right ovarian tissue on bedside endovaginal ultrasound.

(2.7 vs 2.0 days) [3]. Furthermore, Doppler ultrasound may be most helpful in predicting ovary viability preoper- atively [5,6].

Early diagnosis of ovarian torsion is critical because prompt surgical management can salvage the ovary. Older studies have noted salvage rates of 9% or less [2,7]. A recent study found an overall salvage rate of 27% in pediatric patients with Acute ovarian torsion who underwent laparot- omy, indicating new optimism that the ovarian salvage rate may be higher than previously thought [8].

In cases of ovarian torsion, bedside ultrasound can lead to decreased time to diagnosis and early surgical interven- tion, increasing the chance of successful ovarian salvage. Absent flow detected by Doppler ultrasound is highly predictive of ovarian torsion. However, because normal Doppler results do not rule out torsion, it is important to maintain High clinical suspicion for an ovary that has undergone torsion with subsequent detorsion.

Sonia Johnson BA Keck School of Medicine University of Southern California Los Angeles, CA 90033, USA

J. Christian Fox MD, RDMS Kristi L. Koenig MD

Department of Emergency Medicine

University of California Irvine Medical Center Orange, CA 92868, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2005.10.017

References

1. Lambert M, Villa M. Gynecological ultrasound in emergency medicine. Emerg Med Clin North Am 2004;22:683 - 96.
2. Mordehai J, et al. Torsion of the uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg 1991;26(10):1195 - 9.
3. Ben-Ami M, Perlitz Y, Haddad S. The effectiveness of spectral and Color Doppler in predicting ovarian torsion: a prospective study. Eur J Obstet Gynecol Reprod Biol 2002;104:64 - 6.
4. Pena JE, Ufberg D, Cooney N, Denis A. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril 2000;73(5): 1047 - 50.
5. Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a tossed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr Radiol 2002;32:586 - 8.
6. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462 - 5.
7. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med 2001;38(2):156 - 9.
8. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in Pediatric populations. Arch Pediatr Adolesc Med 2005;159:532 - 5.

Case reports of death after nonionic iodine contrast medium injection during Spiral computed tomography scan performed for suspected pulmonary embolism

We report 2 cases of fatal cardiogenic pulmonary edema (CPE), which appeared to be precipitated by the use of nonionic contrast iodine medium during spiral computed tomography scans performed for suspected PE.

A 49 -year-old man was admitted with acute dyspnea. He had a 20 - pack-year smoking history and also a history of massive alcohol ingestion. He had been treated for bronchogenic carcinoma, with a left pneumonectomy in 1996. At admission, the pulse rate was 137 beats per minute; arterial blood pressure was 142/69 mm Hg; the