Clinical diagnosis
Case 84
【Progress】
She was transported to an expert gynecology hospital with our physician together using an ambulance car.
【Discussion】
As gynecologic torsion, ovarian torsion, adnexal torsion, uterus torsion and subserous leiomyoma (subserosal fibroids) torsion are listed (1-4). These torsions cause severe abdominal pain in women and it is difficult to distinguish from other acute abdomen diseases. If the torsion is partial or spontaneously untwisting, abdominal pain might subside to hours, days and weeks. However, tight twisting can lead to necrosis, requiring speedy treatment.
Ovarian torsion occurs usually associated with ovarian cyst or dermoid cyst. Adnexal torsion is also associated with an ipsilateral ovarian tumor, ovarian cyst or dermoid cyst which are the same cause as ovarian torsion. In the case of adnexal torsion, fallopian tube wall thickening such as target-like formation is found. Irrespective of ovarian torsion or adnexal torsion, thickened wall (3 mm or greater) of the cystic mass is the main finding (1). Concentric or eccentric wall thickening is usually found. Although the torsion degree varies, the stronger torsion increases, the greater ischemic damages such as hemorrhagic necrosis are induced. Hemorrhagic cyst and hemoperitoneum with CT values of 50 or greater indicate the possibility of tight torsion of vessels, implying hemorrhagic infarction. Movement of the uterus to the torsion side probably due to the drawing can be noted. In the literature, eccentric wall thickening of the adnexal cystic mass was significantly seen in the case with hemorrhagic torsion compared to that without hemorrhagic torsion (1, 3, 4). In the other words, non-hemorrhagic torsion has the difficulty to diagnose in non-enhance CT or MRI. However, it is important to differentiate torsion with hemorrhagic necrosis from that without for treatment to retain ovary viability.
Torsion of ovarian pedicle or adnexal component causes blockades initially venous and becomes arterial. CT and MRI reflect the situation of the degree of the torsion. According to the report of Rha et al (1), in the case of adnexal torsion, the common findings on CT and MRI, include fallopian tube thickening (84%), cystic tumor wall thickening (76%), asicitis (64%), uterine deviation to the torsion site (36%), hemorrhagic thickened tube (16%), hemorrhagic cystic lesion (8%) and hemoperitoneum (8%). MRI with fat-suppression T1-weighted sequence and Gd-enhanced T1weighted sequence can help to detect hemorrhage and the absence of vascular supply that suggests hemorrhagic infarction.
In our case, T1 weighted images showed thickened cystic wall with high signal intensity, indicating hemorrhage. Diffusion weighted images and ADC map showed high signal intensity and low signal intensity, respectively, indicating diffusion disorder associated with uterus deviation to the right torsion side.
【Summary】
We present a twenty three-year-old female suffering from lower abdominal pain for two days. Pelvic MRI showed right ovarian cystic lesion with edematous and hemorrhagic rim, indicating ovarian torsion. Uterus slightly deviated to the right side. We should keep in mind that ovarian cyst and dermoid cyst are the predominant factors of causing ovarian and adnexal torsion and the main findings of MRI or CT include edematous and hemorrhagic thickened wall of cystic lesion, adnexal mass indicating the peduncle or fallopian tube thickening, ascites and uterus deviation to the torsion site.
【References】
1.Rha SE, et al. CT and MR Imaging Features of Adnexal Torsion. RadioGraphics 2002; 22:283-294
2.Shrestha E, et al. Torsion of Pedunculated Subserous Myoma. Journal of Medical Cases. 2011; 2: 62-63
3.Duigenan S, et al. Ovarian Torsion: Diagnostic Features on CT and MRI With Pathologic Correlation. American Journal of Roentgenology. 2012;198:122-131
4.Chang HC, et al. Pearls and pitfalls in diagnosis of ovarian torsion. RadioGraphics 2008; 28:1355-1368
2017.12.13