Ovarian Torsion Stephanie Doniger MD February 2008 Ovarian

Ovarian Torsion Stephanie Doniger, MD February, 2008

Ovarian Torsion • Twisting of the ovary on its pedicle • 60% on right • Restore perfusion, prevent necrosis • Compromising blood supply • Ischemia: acute pain • Surgical emergency!

Ovarian Torsion • Incidence 2. 7% • Rare in infants, children (17%) • Menarche • Cysts or masses (50 -60%) • 4 -6 cm • Pregnancy @ 4 -16 th weeks

Presentation • Mimics other causes of AP • Sudden onset severe pain • • Focal, constant Unilateral, lower abdominal/pelvic pain • Nausea, vomiting or urinary sx’s

Presentation • Intermittent exacerbations • Torse/detorse • +/- painful mass @ abdomen or pelvis • PE

Work-Up • Pregnancy test • Labs • • • Usu. not helpful R/o other causes AP Leukocytosis in children

Work-Up/Diagnosis • Color flow Doppler US • Visualize blood flow to ovary • CT: ovarian enlargement • Laparoscopic visualization

Prognosis • Salvage rates 10 -27% • Up to 24 -hrs after Sx onset • Complications • • • Infection, adhesions, Chronic pain Infertility

US: Questions • Abnormalities of the ovary • Ovarian cysts: ruptured, hemorrhagic • Ovarian torsion

US: Torsion • Ovarian enlargement • • Mass, cyst Unlikely w/normal ovarian size • Absent blood flow

US: Technique

US: Technique • Patient supine, thighs abducted • Endovaginal 5 -7. 5 MHz • Empty bladder • Full bladder • Transabdominal 3 -5 MHz • Gray-scale • Doppler

Anatomy • Ovaries anterior & medial to iliac vessels • 2 x 3 cm • Pedicle • • Broad ligament, fallopian tube Uterine a & v, adnexal, uterine branches

Anatomy

Vascular Anatomy

Normal Ovary

Ovarian Pathology • Cysts • • Hemorrhagic & simple Masses • Follicular rupture • Complex fluid collections • Infection (TOA), ectopic

Ovarian Cysts

Ovarian Masses

Sonographic Signs • Mass +/- pelvic fluid • Thickening of wall • Cystic hemorrhage • Twisted pedicle • • Whirlpool, snail shell, target Dilated veins

Sonographic Signs Whirlpool Sign Snailshell Vijayarghavan. J Ultrasound Med 23: 1643 -1649

Sonographic Signs Whirlpool Sign Vijayarghavan. J Ultrasound Med 23: 1643 -1649

Sonographic Signs Target Sign String of Beads Vijayarghavan. J Ultrasound Med 23: 1643 -1649

Doppler: Torsion • Absence of flow • Early or partial torsion • Arterial or venous flow can be maintained

Doppler: Torsion • False (-) • • • Early: arterial blood flow preserved Impaired venous/lymphatic drainage Period of de-torsing

Doppler: Color vs. Spectral

Doppler: Torsion • False (+) • • • Salpingitis (tumor) Endometriosis Hemorrhagic cyst w/edema

Doppler: Normal Flow

Doppler: Cyst

Doppler: Torsion

Important Points • Risk factors for torsion • Important to scan in multiple planes • Normal Doppler imaging does NOT rule out torsion! • Clinical suspicion • Take the ovary seriously!

References • • • Baren JM, Rothrock SG, Brennan JA, Brown L. Pediatric Emergency Medicine. “Ovarian Torsion”. Elsevier 2008: 690 -1. Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound. “Gynecological Concepts: Ovarian Torsion. ” Mc. Graw-Hill 2008: 362. Schraga ED, Kulkarni R, Blanda M. “Ovarian Torsion” e. Medicine. Jan 29, 2007. Gaspari RJ, Fox JC, Sierzenski PR. Emergency Ultrasound: Principles and Practice “Ovarian scanning protocol”. Mosby 2006: 141 -156 Vijayaraghavan SB. Sonographic whirlpool sign in ovarian torsion. J Ultrasound Med. 2004. 23: 1643 -1649.

QUESTIONS?