1. 12 yoF presents with several day history of abdominal pain and anorexia. Denies emesis, changes in bowel movements and fevers. LMP was 2 weeks ago. T 37.3C, P 112, BP 104/53, RR 20 Her abdomen is nondistended, moderately tympanic to percussion. WBC 18.3k, Negative UA Case

2. { Twist and Shout: Isolated Tubal Torsion Anthony Castelli University of Washington School of Medicine

3. Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey Samir Alexandre Boukaidi, Jerome Delotte, Henri Steyaert, Jean Stéphane Valla, Christophe Sattonet, Jerome Bouaziz, André Bongain Isolated fallopian tube torsion in pediatric and adolescent females: a retrospective review of 15 cases at a single institution Casey RK, Damle LF, Gomez-Lobo V.

4.  Mean age 13 years old (8-18)   Isolated fallopian tube torsion has a reported incidence of 1 per 1.5 million in reproductive age women.   Incidence in pediatric and adolescent girls is unknown   Affects premenarcheal and menarcheal women Epidemiology

5. Intrinsic FactorsExtrinsic Factors Congenital malformation(Para) ovarian and tubal mass HydrosalpinxUterine enlargement Tubal ligationAdhesions Tubal neoplasmHemodynamic alteration Abnormal peristalsisSudden changes in position or trauma HypermobilityIncreased tubal motility at mid- cycle Spasm Pathogenesis

6.   8 patients (53%) were found to have associated cyst or hydrosalpinx (Casey).   Torsion of the right fallopian tube is more common, related to fixation of the left tube by the sigmoid colon and mesentery   Boukaidi L tube 65%   Narayanan L tube 50%   Casey L tube 40%   Asymptomatic pelvic inflammation during childhood, causing a distal occlusion, hydrosalpinx, and then torsion once puberty begins

7.  Acute lower abdominal pain  Right, left or diffuse  Onset range from days (67%) to weeks  Nausea and vomiting  Afebrile  Normal CRP  +/- elevated WBC Clinical Presentation

9.   Appendicitis   Pyosalpinx/PID   Adnexal cyst rupture   Ovarian torsion  N  Neoplasm   Bowel obstruction Differential Diagnosis

10.   Delay in making a diagnosis due to the lack of specific findings   Only 4/15 patients were suspected to have fallopian tube torsion prior to surgery (27%) (Casey)   An accurate preoperative diagnosis based on imaging was obtained in only 4/13 cases (31%) (Boukaidi)   Only surgery establishes a definitive diagnosis Diagnosis

11.   Transvaginal US imaging provided superior resolution compared to transabdominal US; but transabdominal US were more appropriate due to the young age and sexual inactivity of the patients   Sonographic findings included dilated tubular structures in 6 of 10 cases   5 of 6 had a dilated tube adjacent to a normal ipsilateral ovary Fallopian tube torsion in the pediatric age group: radiologic evaluation. Narayanan S, Bandarkar A, Bulas DI.

12.   Normal-appearing uterus and normal- appearing ovaries with normal flow   Fusiform dilated tube representing a torsed tube (60%).   The dilated tube can have thickened echogenic walls with internal debris or hemorrhage (40%).   Beak sign: the tapered end of a dilated tube secondary to twisting (30%).   A torsed tube can mimic a cyst or a multicystic mass.

13.   Doppler evaluation was limited.   CT demonstrated a dilated tube in 3/5 cases and an adnexal mass in the remaining 2.   On sonography and CT, 9 of 10 cases had the diagnosis of tubal torsion correctly suggested prospectively.

14.  Salpingectomy  Detorsion  Detorsion and interval salpingoneostomy Treatment

15.   The resected tubes showed the persistence of ciliated cells with moderate signs of ischemic infarction in 50% (n = 3/6) of the cases (Boukaidi).   Definitive treatment.   Can raise future issues with infertility if the remaining tube is compromised. Salpingectomy

16.  Detorsion and puncturing of the tube  High risk of recurrence if just detorsed  3/3 recurrence within 90 days (  3/3 recurrence within 90 days (Boukaidi)   Raziel case report had recurrence within 2 years Detorsion

17.   1 patient underwent a salpingoneostomy after detorsion.   The clinical and ultrasound assessment showed no signs of recurrence 26 months later.   Postoperative fertility was not evaluated. Detorsion and Interval Salpingoneostomy

18. Proposed pathway

19.   Tubal torsion is a rare and often misdiagnosed disease.   No specific exam findings, but US is usually able to identify a torsed fallopian tube.   The exact correlation between the duration of torsion and nonviability is unclear.   Detorsion alone has high risk of recurrence.   Long-term fertility outcomes must be further assessed for more definitive decisions regarding surgical management. Summary

20. Boukaidi SA, Delotte J, Steyaert H, et al. Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey. J Pediatr Surg. 2011;46(7):1425-1431. Casey RK, Damle LF, Gomez-Lobo V. Isolated fallopian tube torsion in pediatric and adolescent females: a retrospective review of 15 cases at a single institution. J Pediatr Adolesc Gynecol. 2013;26(3):189-192. Narayanan S, Bandarkar A, Bulas DI. Fallopian tube torsion in the pediatric age group: radiologic evaluation. J Ultrasound Med. 2014;33(9):1697-1704. Raziel A, Mordechai E, Friedler S, Schachter M, Pansky M, Ron-El R. Isolated recurrent torsion of the Fallopian tube: case report. Hum Reprod. 1999;14(12):3000-3001. van der Zanden M, Nap A, van Kints M. Isolated torsion of the fallopian tube: a case report and review of the literature. Eur J Pediatr. 2011;170(10):1329-1332. References