Incidental Diagnosis of Ovarian Torsion Due to a Krukenberg Tumor Originating from Gastric Cancer: A Case Report.

BACKGROUND: Benign lesions cause ovarian torsion more commonly than malignant ovarian tumors. Further, Krukenberg tumors have rarely been reported to cause ovarian torsion. CASE PRESENTATION: Herein, we present the case of a patient with an incidentally discovered ovarian mass, which was finally diagnosed as a Krukenberg tumor accompanying ovarian torsion with primary stomach cancer. We further review the clinical, imaging, and histological features of Krukenberg tumors. CONCLUSION: Radiologists should be aware of Krukenberg tumors that may present with ovarian torsion.

Rethinking ovary preservation by adnexal torsion reversal in adolescents: a case of delayed diagnosis.

BACKGROUND: This article discusses the management of an adolescent woman with a delayed diagnosis of adnexal torsion (AT) whose ovaries were successfully preserved. CASE PRESENTATION: The patient was a 14-year-old female teen admitted with the chief complaint of lower abdominal pain for 3 days and worsening pain for 2 days. Magnetic resonance imaging suggested a high possibility of torsion in the anterosuperior uterine mass and was accompanied by severe ovarian edema, bleeding, and enlargement. Intraoperatively, the left fallopian tube was characterized by thickening and torsion and appeared blackish purple. The left fallopian tube paraovarian cyst was about 20 cm in size, and the left adnexa was twisted 1080° along the left infundibulopelvic ligament (suspensory ligament of the left ovary). The left ovary appeared blackish purple, with an enlarged diameter of about 10 cm. At the request and with the informed consent of the patient's parents, we preserved the left ovary and removed the left fallopian tube. The results of the endocrine, ultrasound, and tumor marker tests were normal 1 month after surgery. Follicles and blood flow signals seen in ultrasound examinations indirectly proved the successful preservation of the left ovary in the follow-up. CONCLUSIONS: Our attempt to preserve the ovaries in an adolescent with a delayed diagnosis of AT was successful.

When is it too late? Ovarian preservation and duration of symptoms in ovarian torsion.

This 10-year retrospective study between 2008 and 2018, aims to investigate the duration of symptoms of ovarian torsion and the subsequent rate of ovarian preservation. Eighty-six women with surgically confirmed ovarian torsion were included. The median duration from the onset of pain symptoms to presentation (26.0 vs 6.0 h, p < .001) and from presentation to surgery (11.0 vs 5.5 h, p = .010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary (94.9% vs 76.9%, p = .026). Awareness of the condition among the community and healthcare is crucial and routine investigations should not delay management as positive Doppler flow on ultrasound does not exclude an ovarian torsion.Impact StatementWhat is already known on this subject? Ovarian torsion is a gynaecological emergency and may lead to ovarian necrosis, infection and peritonitis. Early recognition is essential in preserving the ovary, particularly in patients with future fertility aspirations. Currently there is no consensus regarding the time period of ovarian viability after the onset of symptoms.What do the results of this study add? We have demonstrated a significant difference in the duration from the onset of symptoms to surgery. Furthermore, the duration from the onset of symptoms to presentation (26.0 vs 6.0 h, p<.001) and from presentation to surgery (11.0 vs 5.5 h, p=.010) were significantly longer in women who required an oophorectomy compared to women who had conservative surgery. There was no significant difference in symptoms, signs or investigations except ultrasound finding of an enlarged ovary.What are the implications of these findings for clinical practice and/or further research? Women with known ovarian cysts in particular should be educated of the risk of ovarian torsion. Routine investigations should not delay management as it does not exclude an ovarian torsion. Although our study suggests that early presentation and management would reduce the risk of oophorectomy, prospective studies are required to confirm the findings.

Pregnancy outcomes following laparoscopy for suspected adnexal torsion during pregnancy.

OBJECTIVE: To evaluate pregnancy outcomes of women with surgically confirmed adnexal torsion (AT) as compared to those in whom AT was ruled out. METHODS: A retrospective cohort study in a tertiary medical center. All pregnant women who underwent diagnostic laparoscopy due to suspected AT between 3/2011 and 4/2020 were included. We compared maternal, delivery and neonatal outcomes of both groups. We further compared women with confirmed AT to a control group of women who did not undergo laparoscopy during pregnancy. RESULTS: During the study period, 112 women met the inclusion criteria. AT was confirmed in 93 cases (83.0%). Baseline characteristics did not differ between groups, excluding the rate of previous AT [5.4% in the torsion vs. 26.3% in the no-torsion group, odds ratio (OR) 0.15, 95% confidence interval (CI) 0.04-0.62, p = .004], and nulliparity rate (57.0% in the torsion vs. 31.6% in the no-torsion group, OR 2.41, 95%CI 1.004-8.21, p = .043). Pregnancies conceived by assisted reproductive technology were more common in the AT group compared to the no-AT group (46.2% vs. 10.5%, OR 7.21, 95%CI 1.59-33.45, p = .002). Miscarriage and stillbirth rates, gestational age at delivery, delivery characteristics and neonatal outcomes were favorable and did not differ between groups. Outcomes of pregnancies with confirmed AT did not differ from a control group of women who did not undergo laparoscopy during pregnancy. CONCLUSION: Pregnancy outcomes among women who underwent laparoscopy for a suspected AT during pregnancy were reassuring, irrespective of the surgical findings and gestational week. Outcomes did not differ when compared to pregnant women who did not undergo laparoscopy. SYNOPSIS: Maternal, fetal and neonatal outcomes among women who underwent laparoscopy for suspected adnexal torsion during pregnancy are reassuring, irrespective of the surgical findings and gestational week.

Abdominal Pain in the Emergency Department: Missed Diagnoses.

Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.

Abdominal Pain Mimics.

Abdominal pain is a common reason for emergency department visits, with many patients not receiving a definitive diagnosis for their symptoms. Non-gastrointestinal causes need to be considered in the workup of abdominal pain. A high index of suspicion is needed in order to develop a broad differential, and a thorough history and physical examination is paramount. This article will discuss some of these diagnoses, including can't miss diagnoses, common non-abdominal causes, and rare etiologies of abdominal pain.

Ovarian torsion in a twin pregnancy at 32 weeks and 6 days: A case-report.

BACKGROUND: Ovarian torsion during pregnancy is a rare event and occurs mostly during the first trimester. This is the first case describing the diagnosis and management of an ovarian torsion at 33 weeks in a twin pregnancy with a normal term delivery. CASE SUMMARY: The patient presented with irregular uterine contraction due to an acute abdominal pain in the right iliac fossa. A cyst was discovered during the ultrasound scan on the right ovary and a torsion was highly suspected. A small laparotomy facing the ovarian mass after an ultrasound guidance was chosen. The patient finally delivered at 37 weeks. CONCLUSION: The clinic holds a preponderant place in the diagnosis of ovarian torsion. Our surgical approach by laparotomy under ultrasound guidance was less risky than by laparoscopy.

Ovarian torsion: can we save the ovary?

OBJECTIVE: The purpose of this study is to evaluate the correlation between visually appearing ovarian necrosis and necrosis in histopathology in patients with ovarian torsion; and to identify predictive factors of ovarian necrosis. METHODS: This is a retrospective study. All women admitted to the hospital with a diagnosis of suspected ovarian torsion from January 2014 to December 2018 were recruited. Forty-two patients with a confirmed diagnosis of ovarian torsion were finally included. Correlation analysis was done between visual judgement of ovarian necrosis and necrosis in histopathology. Chi-square was performed to analyze dependence between time from pain onset to surgery, ovarian size in ultrasound, Doppler flow, and histopathological analysis. RESULTS: Thirty-one ovaries were visually judged as necrotic. Only five of them (16%) had histopathologically confirmed necrosis, 20 (64.5%) had hemorrhage or congestion, and 6 (19%) had normal ovarian tissue, p = 0.349. Development of ovarian necrosis showed to be dependent on time from onset of pain to surgery. All patients with necrotic ovaries in histopathology underwent surgery after 24 h of pain onset, while there was no necrosis in those who had surgery before 24 h. (p = < 0.05). There was no relationship between ovarian size measured by ultrasound and necrosis (p = 0.265), as well as color flow in ultrasound and necrosis (p = 0.388). CONCLUSION: Visual assessment of ovarian necrosis intraoperatively is not a good predictor of real necrosis in histopathology. To preserve the ovary, surgical management should not be delayed.

"Follow the Fallopian tube": A technique to improve sonographic identification of ovaries in children.

Ovary detection is the first step in confirming ovarian lesions. The daughter cyst sign is widely used for this purpose; however, it is not always applicable. Recent improvements in image resolution allow Fallopian tube delineation, which can serve as a guide to identify the ovary. This anatomical approach ("follow the Fallopian tube" technique) comprises three steps: (1) confirm the uterus; (2) follow the Fallopian tube; and (3) find the ovary. Other applications of this approach include the differentiation between nonovarian and ovarian masses and ruling out ovarian torsion and an auto-amputated ovary.

Ovarian Incarceration and Torsion in Single-Ovary Versus Multiple-Reproductive Organ Prolapse in Female Inguinal Hernia: A Retrospective Study of 510 Infants Who Underwent Laparoscopic Hernia Repair.

Purpose: Although inguinal hernia repair is common in infants, few studies have focused on the condition in female infants. In female infantile inguinal hernia, there is a risk of oophorectomy when torsion and strangulation occur due to ovarian prolapse. We aimed to evaluate the risks of ovarian incarceration and torsion in single-ovary versus multiple-reproductive organ prolapse in female infantile inguinal hernia. Methods: Females ≤12 months old who underwent laparoscopic transabdominal inguinal hernia repair from September 2012 to December 2019 were retrospectively analyzed. If manual reduction failed at initial diagnosis, surgery was performed within 24 hours in all incarceration cases. The clinical characteristics and surgical outcomes were compared between those with single-organ versus multiple-organ prolapse. Results: Of 510 patients, 465 (91.2%) had single-organ prolapse, most commonly a single ovary (381/465), followed by intestine (84/465). Forty-five patients (8.8%) had multiple-organ prolapse, most commonly a single ovary plus intestine (27/45), followed by both ovaries plus the uterus (10/45). The manually irreducible incarceration rate was higher in patients with multiple-organ prolapse (57.8%) than single-organ prolapse (23.4%; P < .000). In patients with ovarian incarceration, the ovarian torsion rate was higher in the single-ovary group (38/109, 34.9%) than the multiple-organ group (1/26, 3.8%; P < .000). There was no significant difference between the two groups in recurrence or oophorectomy rate. Conclusion: Most female infantile inguinal hernias involve ovarian prolapse. There is a high risk of incarceration in multiple-organ prolapse and a high risk of ovarian torsion in single-ovary prolapse.

A Challenge in Diagnosis and Management: Uterine Torsion in Childhood.

BACKGROUND: Uterine torsion is a rare event, which mostly reported in females with a gravid uterus and is exceptionally rare in children. CASE: A 9-year-old girl presented with 3 days of intermittent lower abdominal pain. Ultrasound revealed an ovarian mass, but laparotomy revealed an ischemic enlarged ovary and uterus rotated 180°. No reperfusion occurred after 60 minutes. A subtotal hysterectomy and right salpingoophorectomy were thus performed. CONCLUSION: Uterine and adnexal torsion presents with symptoms similar to those of adnexal torsion. Delays in diagnosis and referral continue to be an issue, resulting in suboptimal outcomes. Uterine torsion, although exceedingly rare in childhood, appears to occur only in the setting of ovarian masses, which provide the impetus for the rotational force to the elongated cervix of the prepubertal uterus.

Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio Might Predict Pediatric Ovarian Torsion: A Single-Institution Experience and Review of the Literature.

STUDY OBJECTIVE: To determine clinical and laboratory characteristics of ovarian torsion (OT; n = 28) compared with a non-OT control (OC; n = 64) group. DESIGN: Retrospective single-center review performed between January 2006 and December 2016. SETTING: Academic department of pediatric surgery. PARTICIPANTS AND INTERVENTIONS: Postoperative diagnosis of pediatric ovarian pathology (International Classification of Diseases, 10th Revision code N83) in 88 patients who underwent 92 surgeries for suspected OT, aged from 3 days to 17.8 years. MAIN OUTCOME MEASURES: Predictive value for OT according to biometric, procedural, and laboratory parameters at the time of admission. RESULTS: Compared with OC, OT in patients aged older than 1 year was associated with elevated values regarding white blood cell count, neutrophils, neutrophil to lymphocyte ratio (NLR; all P < .001), platelet to lymphocyte ratio (PLR; P = .003), platelets (P = .011), and a trend toward raised C-reactive protein (P = .054), whereas lymphocytes and lymphocyte to C-reactive protein ratio (both P < .001) were decreased. Using receiver operating characteristic analysis for differentiating OC from OT, besides lymphocytes and NLR (both area under the curve > 0.9), PLR elicited strongest discriminatory accuracy (area under the curve = 0.946 ± 0.037; P < .001; sensitivity 82%; specificity 90%). At binary logistic regression analysis PLR (P = .018) was independently predictive of OT. OT was suspected on ultrasound imaging in 15/18 (83%), showed a right-sided dominance in 13/18 (72%), and was associated with younger age (P = .003). No differences regarding laboratory or procedural parameters in patients aged younger than 1 year were discerned. CONCLUSION: Blood count indices such as PLR, NLR, and lymphocyte to C-reactive protein ratio might be helpful in identification of inflammatory processes as induced by ischemia in OT. Together with ultrasound and clinical features, these parameters constitute potential predictors of OT in girls aged older than 1 year.

Interdisciplinary Care and a Focus on Fertility Preservation When Multi-cystic Ovaries Cause Ovarian Torsion: A Case of a 9-year-old Girl with Severe, Undiagnosed Hypothyroidism.

BACKGROUND: Ovarian torsion can occur in Van Wyk Grumbach syndrome, a disorder characterized by severe primary hypothyroidism and ovarian enlargement. To date, all documented cases of torsion in this setting describe oophorectomy, which has significant hormonal and fertility implications. CASE: A 9-year-old pubertal girl presented to the emergency room with abdominal pain. Magnetic resonance imaging demonstrated bilateral, multi-cystic ovaries. Operative laparoscopy confirmed unilateral adnexal torsion, and detorsion without oophorectomy was accomplished. Postoperative laboratory tests revealed severe primary hypothyroidism. Ovarian size was reduced with hormone replacement therapy. SUMMARY AND CONCLUSION: This case demonstrates that prompt interdisciplinary intervention and awareness of severe hypothyroidism as a cause of ovarian torsion related to enlarged, multi-cystic ovaries may reduce the rate of oophorectomy, allowing preservation of pediatric patients' future fertility, and reducing morbidity postoperatively through prompt, long-term thyroid supplementation.

Maternal and perinatal outcomes following laparoscopy for suspected adnexal torsion during pregnancy: a multicenter cohort study.

PURPOSE: To investigate the association of maternal and perinatal outcomes with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion during pregnancy. STUDY DESIGN: This is a multicenter retrospective study and telephone questionnaire of urgent laparoscopies that occurred during pregnancy for suspected torsion between 2004 and 2019 in three tertiary medical centers. Pregnancy outcomes of women with the surgical diagnosis were compared with those whose laparoscopy was negative for adnexal torsion. Multivariable regression modeling was applied to control for possible confounders ((adjusted odds ratios (aOR) ± 95% confidence intervals (CI)]. RESULTS: The study cohort included 186 women. Adnexal torsion was surgically found in 129/186 (69.4%) cases. The torsion group was characterized by higher rate of nulliparity, fertility treatments and multiple gestations as well as lower rates of previous cesarean delivery. Live birth was reported for 171 (91.9%) pregnancies, and the miscarriage rate was significantly higher in the non-torsion group. Women with torsion were more likely to be hospitalizes due to preterm labor; however, rates of preterm delivery were comparable between the groups (10.8% vs. 10.9%, p = 0.99). Logistic regression analysis had demonstrated that the performance of laparoscopy prior to 8 weeks of gestation was the only independent factor associated with miscarriage (8.23, 2.01-33.67). CONCLUSION: Pregnancy outcomes following the diagnosis of adnexal torsion throughout gestation were overall favorable. Laparoscopic procedure during early stages of pregnancy was associated with higher rates of miscarriage, regardless of the surgical diagnosis of adnexal torsion.

Clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women: a retrospective study.

BACKGROUND: Adnexal torsion during pregnancy is a gynecological emergency. Delayed diagnosis and treatment can cause ovarian necrosis and fetal loss. This study assessed the clinical characteristics, treatment and outcomes of adnexal torsion in pregnant women. METHODS: A retrospective study was conducted at a tertiary center between January 2008 and January 2018. Eighty-two pregnant women with surgically confirmed adnexal torsion were included. The clinical characteristics, ultrasound data, surgical interventions and pregnancy outcomes were analyzed. RESULTS: The median age of the patients was 28 (range, 18-38) years. The median gestational age was 11 (range, 6-31) weeks: 53 (64.6%) were in the first trimester, 21 (25.6%) were in the second trimester, and 8 (9.8%) were in the third trimester. The most common symptoms and signs were sudden pelvic pain (100%) and adnexal or pelvic masses (97.6%), followed by nausea and vomiting (61%). The Doppler blood flow signal disappeared in 62.5% of the patients. Sixty-three (76.8%) patients underwent laparoscopy, and 29 (24.2%) underwent laparotomy. The median gestational age in patients undergoing laparotomy was higher than that in those undergoing laparoscopy (26 weeks vs 10 weeks, p < 0.001). Fifty-three (64.6%) patients underwent conservative surgery, with 48 detorsions and cystectomies, 2 detorsions and cyst fenestrations, 1 detorsion only and 2 salpingectomies only. Twenty-nine (25.4%) patients underwent unilateral salpingo-oophorectomy. There were no cases of postoperative thrombosis, spontaneous abortion or recurrence during the same pregnancy. Seven patients underwent simultaneous artificial abortion. One patient experienced intrauterine fetal death, and 74 patients had live births. CONCLUSION: Surgical intervention was required as soon as possible. Laparoscopic conservative surgery is safe and may be appropriate to preserve ovarian function.

A young girl with right ovarian torsion and left ovarian ectopy.

BACKGROUND: Mayer-Rokitansky-Küster-Hauser (MRKHS) syndrome refers to congenital hypoplasia/aplasia of the uterus, the cervix and the upper 2/3 of the vagina, in females with normal ovaries and fallopian tubes, secondary sexual characteristics and 46 XX karyotype. This condition originates from abnormal development of Müller's paramesonephric ducts in the early stages of embryonic development. Kidney agenesis or malformations are the most commonly associated with unilateral kidney agenesis. Ovaries may be ectopic in 16-19% of MRKHS patients. Primary amenorrhoea, due to the absence of the uterus, is the most common presentation. Female karyotype confirmation is mandatory to differentiate it from complete androgen insensitivity syndrome and 17-alpha-hydroxylase deficiency. The management of MRKHS is multidisciplinary in order to encompass psychological, medical and surgical issues. CASE PRESENTATION: A four-year-old girl, presented to the emergency department complaining of left groin swelling noted 2 days earlier. The patient had recently been evaluated for an episode of acute abdominal pain and vomiting, with a final diagnosis of right ovarian torsion. At that time, the ultrasound imaging was not able to identify the left kidney, the left ovary and uterus. Surgical abdominal exploration confirmed the right ovarian torsion and was not able to identify the left kidney and the left ovary. Only a remnant of the uterus was present. Therefore, the right ovary was removed, and a diagnosis of MRKHS was made. Ultrasound imaging showed a left inguinal hernia. The hernial sac consisted of a solid oval vascularized formation suggestive of an annexe. The patient underwent a surgical procedure to correct the left inguinal hernia. In the operating setting, the presence of a vascularized, ectopic ovary carrying the tuba inside the hernial sac was observed. CONCLUSIONS: In front of a patient with ovarian torsion and anatomical features suggestive of MRKHS, both the ovaries should always be searched for, with a high suspicion threshold for extrapelvic ovary. Identifying the ectopic ovary, in this case, helped to preserve patient fertility, avoiding a possible torsion.

A new type of abdominal incision for emergencies in pregnancy: a case report.

Adnexal torsion in pregnancy is a rare gynecologic emergency that causes severe abdominal pain. The current paper reports a case of a woman with 18 weeks pregnancy who was referred to our tertiary clinic with sudden lower abdominal pain. Ultrasound scan showed a very large multicystic adnexal torsion mass on the right side displacing the gravid uterus to the anterior left. An oblique paramedian incision was made for right salpingo-oophorectomy. To our knowledge the incision presented in this case has not been described in the literature previously. We suggest an alternative incision to be used during pregnancy especially for emergencies due to an adnexal mass.

Histopathological and biochemical assessment of a novel diagnostic method for ovarian torsion.

Ovarian torsion is agynecologic emergency that affects females of all ages. Early diagnosis is important to preserve ovarian function. The false positive rate for sonographic diagnosis of ovarian torsion is 50%; therefore, a new real-time approach is required to improve diagnostic accuracy. We investigated diffuse reflectance spectroscopy for diagnosing ovarian torsion. Spectroscopic measurements were performed in vivo prior to, during and after detorsion. After bilateral oophorectomy, hemoxygenase and myeloperoxidase enzyme activity in ovarian tissue was evaluated and the tissues were examined for pathology. Spectroscopic data were compared to histopathological and biochemical data to assess the diagnostic value of the spectroscopic method for differentiating healthy and damaged ovarian tissue. We found a good correlation between spectroscopy and histopathology. We also found a correlation between the spectroscopic data and heme oxygenase enzyme activity. We found no correlation between the histopathological tissue damage score and myeloperoxidase enzyme activity. Diffuse reflectance spectroscopy may be of prognostic and diagnostic value for ovarian torsion in vivo.