by So it’s a busy weekday at Coney Island Hospital. You get an upgrade and it’s for a 41 year old woman with severe RLQ abdominal pain. You see she’s writhing in bed, crying and guarding. Vitals are normal but she is slightly tachycardic. What do you do next?
History! History!
The patient is not fully cooperating with your questioning because of the pain but tells you it started 2 hours ago and that the pain is sharp, 10/10 constant and nonradiating. She woke up with this pain and had 2 episodes of vomiting and is still nauseous. You press on her abdomen and she’s tender in the RLQ region. She tells you had a history of right tubal ligation in 2005 and her LMP was a few weeks ago.
What’s in your ddx?
- Ectopic Pregnancy
- Appendicitis
- Ovarian Torsion
- Renal Colic
- Biliary Colic
- Pyelonephritis
Pregnancy test is negative and there is no free fluid in on your bedside US.
History alone should be worrisome for ovarian torsion and appendicitis!
You call ultrasound immediately and get this patient under pain control.
Results come back:
US Appendix – appendix not visualized
US Pelvis – Right ovary measures 4.6cmx3cmx3cm with resolving right ovarian complex cystic mass, and left ovary measures 4.5cmx1.5cmx3.1cm with NORMAL flow to both and no free fluid in the cul-de-sac
Lab work up is also unremarkable.
Okay so the patient is better pain control but still uncomfortable. Appendix was not visualized on ultrasound and she’s still tender in RLQ. US Pelvis showed normal flow to both ovaries. You next plan is to get CT abdomen/pelvis to rule out appendicitis.
CT abdomen/pelvis comes back and states that the appendix is not clearly visualized and appendicitis can’t be excluded. There’s nonspecific small amount of fluid in the RLQ with follicle/cyst on the right ovary and a right adnexal lesion or torsion can’t be excluded.
What’s your next move?
You’re getting both a OBGYN and Surgery consult!! Surgery is not impressed with appendicitis but obgyn offers the patient an exploratory laparoscopy for ovarian torsion.
Conclusion. Patient was sent to OR. Was found to have the right ovary torsed around the adnexa with a normal appendix
This patient had a right ovarian torsion!
What are some fast facts we need to know?
-Most common in reproductive age females
-risk factors: ovarian mass and fertility treatments
-most common in the right since the sigmoid colon stabilizes the left side
-causes by either hyper mobility of ovary or adnexal mass
CYSTS GREATER THAN 4cm are more likely to torse 
(Torsed ovary with cyst)
Most common symptoms: nausea and vomiting with acute onset however may occur for days to months intermittently before diagnosis is made
Elderly patients have most risk of their ovaries are enlarged or abnormal. Pediatrics more likely to occur in normal size ovaries.
Patients may or may not have adnexal mass or tenderness. Pregnant patients are at risk mostly in first trimester and higher risk if they received fertility treatments.
67% of patients had normal flow on ultrasound!
CT abdomen/pelvis has Low sensitivity
Ultrasound Findings:
– enlarged ovarian volume (MC finding)
-loss of echogenicity
-midline ovary
-pelvic free fluid
-whirlpool sign (rare)
Surgery should occur 4-6 hours after symptoms started. Get the imaging and consults ASAP! Time is ovary! (And testicle)
Bottom line:
A normal ultrasound and CT scan does not rule out an ovarian torsion (or appendicitis for that matter). If you still have clinical suspicion and the patient has risk factors And/or something doesn’t feel right, get the consults. An ultrasound or CT scan are only as good as the person reading it.
