1. Interesting Case Rounds July 19, 2007 Nadim Lalani R4

2. Case z 13 y F c/o intermittent LLQ/flank pain z Began 7am. Pt went back to bed. Pain again at 12 noon. Phoned Healthlink told to go to ACH ER. Waited until 1:30pm. z Sharp. Radiating to L flank. z No other sympts. z Healthy. Premenarchal

3. z DDX? z What will you look for?

4. P/E: z Initially writhing in pain. Given 50mcg fentanyl and settled somewhat. z Tender L flank. No CVA tender. Not peritoneal. Soft abd. z Ultrasound ordered : y + Torted Ovary w/ multiple cysts, y venous congestion, oedema y absence of arterial flow.

5. Outcome z Pt eventually went to OR z Or findings, torted normal appearing ovary z Attempt to drain cysts z Pt discharged home

6. Ovarian Torsion z Intro: y Torsion = twisting of the ovary on its ligamentous supports often resulting in vasc compromise y 5 th MC gyne emergency y Affects all ages y Since sympts can be non-specific Dx is a challenge

7. z Epidemiology: y 2.7% of gyne surgical emergencies y 80% under 50y, y highest in reproductive ages y increased risk in pregnant and ovarian hyperstimulation

8. z Etiology: y Cysts + neoplasms = 94% Predispose to swing on pedicle. Larger mass more risk y 6% normal ovaries y assoc with vigorous excercise z Pathophys: y Compromise of vasc pedicles impaired blood flow [veins > arteries ] marked engorgement ischemia necrosis peritonitis

9. Pathophys

10. z Fetal/Neonatal period: y Rare y Usually because of cysts, rarely neoplsm y Diagnosed on fetal ultrasound z Childhood/Pre-menarche: y Rare [dont have cysts] y Normal ovaries. y thought to be due to long utero-ovarian ligament

11. z Post-menarche: y Highest risk group y Cysts neoplasms infertility treatment

12. Clinical Picture z Clinical Presentation: y non-specific y Two MC signs are lower abd pain [83%] and adnexal mass [72%] z Neonates: y present w/ in 1 st three months y Feeding intolerance, vomiting, abdo distension, fussy/irritable

13. z Children & older: y Acute onset y stabbing lower abd pain rad to flank/back/groin y assoc w/ waves of N/V y can present w/ peritonitis

14. Diagnostics z Definitive Dx is OR findings z Doppler Ultrasound:[sens/spec high 90s] y Visualise adnexal mass + enlarged ovary + hemorrhage + FF y Diminished/absent flow y Nb Normal Ovary doesnt rule out z Lab: y Serum IL-6

15. Management z Expeditious surgical consult z Less and less oophorectomy more watch and wait [even when dusky] z Fetal [cysts]: y Conservative mgmnt + serial U/S [q4wk] z Neonate [cysts]: y Follow w/ U/S [even neoplasms 1/3 go away] y Cysts 4cm OR

16. z Children & older: y Early OR as possible [one study only 25% salvage in <15yo] y Unlike testes No Statistically reliable time frame. y Rats 4 hour upper limit 100% salvage. y Recuperation of ovary reported w/ up to 72 hours of torsion y One study median 14h for detorsion 82% had N ovaries on f/u y Delay trends towards less salvage

19. Prevention? z higher dose BCP? y no difference z Oophoropexy? y Definitely indicated in: x Normal ovary torsion x Oophorectomy [afix the good one so it doesnt] x some will do with cysts

20. References Growdon, W and M Laufer. Ovarian Torsion