Case Report

Unusual presentation of Acute ovarian torsion in an adolescent

Abstract

Ovarian torsion occurs when an ovary twists about its vascular pedicle. The process causes abdominal pain and will result in ovarian tissue loss if not diagnosed and managed expeditiously. Acute ovarian torsion is an uncommon cause of abdominal pain in adolescents, and, as a result, it is often mistaken for other processes [1]. We present a case of ovarian torsion in an adolescent female who presented with abdominal pain and marked abdominal distension, which was initially suggestive of a gravid abdomen. She was ultimately found to have a very large cystic teratoma of the right ovary with concomitant ovarian torsion. There are no reported cases of ovarian cystic teratoma with acute torsion presenting with an Abdominal mass suggestive of a gravid abdomen.

Ovarian torsion occurs when an ovary twists about its vascular pedicle. The process causes abdominal pain and will result in ovarian tissue loss if not diagnosed and managed expeditiously. Acute ovarian torsion is an uncommon cause of abdominal pain in adolescents, and, as a result, it is often mistaken for other more common etiologies of abdominal pain [1]. We present a case of ovarian torsion in a 15-year-old adolescent girl who originally presented to the ED with abdominal pain and marked abdominal distension. A pregnancy-related compli- cation was in the early differential secondary to her history of increasing abdominal girth and Abdominal examination. Ultimately, the patient was found to have an extremely large cystic teratoma of the right ovary with concomitant right ovarian torsion. There are no reported cases of ovarian cystic teratoma with acute torsion presenting with an abdominal mass suggestive of a gravid abdomen.

A 15-year-old adolescent girl presented to the ED with a chief complaint of abdominal pain. The pain was described as being severe, sharp, and predominantly located in the lower abdomen. The discomfort had been progressively worsening over the preceding 3 to 4 days. She admitted to other Gastrointestinal symptoms including nausea and occasional emesis. She denied being sexually active and

stated that she had not experienced any fever or vaginal discharge. Upon further questioning, she reported that she had experienced occasional abdominal discomfort for a period of 3 months and had noted increasing abdominal girth. She had some Vaginal bleeding approximately 15 days before her ED visit, which she stated was atypical for her period.

Physical examination at the time of initial evaluation in the ED revealed a well-appearing female in no apparent distress. Vital signs were significant for a temperature of 38.6?C and mild tachycardia. Her abdominal examination showed poorly localized moderate abdominal tenderness to palpation. There was no guarding, rebound tenderness, or other evidence of peritoneal irritation. The abdomen was markedly distended. A midline abdominal mass was present, extending from the pelvis to the level of the umbilicus. It was felt that this mass likely represented a gravid uterus, with an estimated uterine fundal height of 20 cm. Pelvic examination revealed no vaginal bleeding or discharge, no cervical lesions, and a closed cervical os.

Pregnancy-related complications such as preterm labor, chorioamnionitis, septic abortion, and Ectopic pregnancy were included in the early differential. A urine B-hcg was ordered and the result was negative. Because of the highly

Fig. 1 Large, midline intraperitoneal mass (long arrow) at the level of the umbilicus (short arrow).

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Fig. 2 Pelvic portion of mass (arrow).

suggestive physical examination, a Serum b-hCG was subsequently ordered and the result was negative as well. After pregnancy was excluded, the differential was expanded to include entities such as gastrointestinal emergencies. Multiple laboratory studies were ordered including a complete blood count and electrolytes. The complete blood count was significant for a white blood cell count of 17300 cells per cubic millimeter. The remainder of the Laboratory workup was unremarkable.

An ultrasound credentialed member of the faculty was asked to perform a bedside transabdominal evaluation. The ultrasound showed a complex cystic mass in the pelvis. No normal uterine or adnexal structures could be identified. To better characterize the mass, abdominal computed tomogra- phy (CT) was ordered. The scan was performed with intravenous and oral contrast. Computed tomography findings included a 10 x 13.6 x 15-cm cystic mass originating in the pelvis and causing significant displacement of adjacent structures. The mass extended from the pelvis to the level of the umbilicus (Figs. 1 and 2).

Pediatric surgery and gynecologic consultations were obtained. Ultimately, the patient was admitted and underwent an Exploratory laparotomy. A very large right adnexal mass was noted with concomitant right ovarian torsion. The ovary had twisted 4 times about its pedicle and was deemed to be nonviable. Right salpingo-oopherectomy was performed and final pathologic analysis confirmed a cystic teratoma with areas of necrosis. The patient did well and was discharged on postoperative day 3.

The differential diagnosis of acute lower abdominal pain in adolescent females is extensive and includes appendicitis, renal colic, Pelvic inflammatory disease, and ectopic pregnancy. A myriad of other diagnoses are possible, among them ovarian torsion. Because acute ovarian torsion is not encountered frequently, it is often confused with other more common conditions [1].

Torsion is essentially a twisting of the ovary on its vascular pedicle. Infarction will result if the twist is not

relieved spontaneously or surgically in a timely fashion [2]. The ovarian salvage rate in cases of confirmed torsion varies in the literature, with the reported salvage rate in adults being higher than that in the pediatric population [2]. Previous series have documented a salvage rate from 0% to 15% in children [3,4].

Retrospective series have shown that the most common presenting symptom in acute torsion is abdominal pain (73%). However, the presentation can be quite varied and often involves nonspecific symptoms such as nausea, vomiting, and anorexia. The most frequent misdiagnosis in ED patients who are later proven to have an ovarian mass and/or torsion was found to be appendicitis (38%) [5].

If the diagnosis of ovarian torsion is suspected clinically, an Imaging study is usually obtained. The most frequent imaging modalities used in this setting are ultrasonography and CT. Ultrasonography is the preferred initial study. It provides good visualization of the female pelvis and can be performed both transabdominally and transvaginally. In addition, it does not expose the patient to ionizing radiation and can provide an assessment of ovarian blood flow through the use of color flow and Doppler techniques. Computed tomography can also be useful, especially when other diagnoses such as appendicitis are suspected. However, CT may be time consuming secondary to the use of oral Contrast agents, is relatively expensive, and exposes the patient to ionizing radiation.

Once diagnosed, the treatment of ovarian torsion is surgical. A decision is made regarding the viability of the ovary at the time of laparotomy. As previously mentioned, only a minority of torsed ovaries are salvageable. Even when the ovary is deemed viable, there may still be a concern for malignancy, etc, and the majority of affected patients undergo salpingo-opherectomy.

Most cases of ovarian torsion are due to some underlying ovarian pathology that predisposes the ovary to twisting. Normal ovaries can undergo torsion, but with a much lower frequency than do pathological ovaries. A retrospective review of children with ovarian torsion by Kokoska et al [1] showed that 84% of the involved ovaries contained cysts and/or neoplastic elements. Mature cystic teratoma accounted for 47% of these cases [1]. Overall, most ovarian masses in children and adolescents are benign [6-8].

Although relatively uncommon, it is important to keep ovarian torsion in the differential of any female child or adolescent with acute abdominal pain. It can be exceedingly difficult to diagnose and can masquerade as many different entities, including a gravid abdomen.

Dixie Griffin MD Stephen A. Shiver MD

Department of Emergency Medicine Medical College of Georgia Augusta, GA 30912-4007, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2007.08.029

Case Report

References

1. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462-5.
2. Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005;159:532-5.
3. Meyer JS, Harmon CM, et al. Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg 1995;30:1433-6.

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1. Mordehai J, Mares AJ, et al. Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg 1991;26:1195-9.
2. Pomeranz AJ, Sabnis S. Misdiagnosis of ovarian masses in children and adolescents. Pediatr Emerg Care 2004;20(3):172-4.
3. Brown MF, Hebra A, et al. Ovarian masses in children: a review of 91 cases of malignant and benign masses. J Pediatr Surg 1993;28:930-2.
4. Goldstein DP, Laufer MR. Benign and malignant ovarian masses. In: Emans AJH, Laufer MR, Goldstein DP, editors. Pediatric and adolescent gynecology. 4th ed. Philadelphia: Lippincott-Raven; 1998. p. 553-85.
5. Kozlowski KJ. Ovarian masses. Adolesc Med 1999;10(2):337-50.