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1251
Case Report
Adnexal William
Torsion:
M. Rosado,
Jr.,1
Diagnosis
Michael
A. Trambert,2
by Using Doppler
Barbara
Torsion of the ovary, and rarely the fallopian tube, is a known cause of acute abdominal pain, especially in postpubertal females. This condition requires rapid surgical intervention to save the ovary. If diagnosis is delayed, other complications such as peritonitis and even death may result [1 2]. It has been theorized that Doppler sonography of the adnexal vessels may facilitate the diagnosis of ovarian torsion by showing a lack of blood flow to the ovary, due to the mechanical torsion of the ovarian vessels [3]. To our knowledge, however, no reports of Doppler assessment in proved cases of adnexal torsion have been published. We report the DoppIer findings in a patient with surgically proved adnexal torsion and note the findings in two others. All three patients had normal adnexal Doppler arterial waveforms and resistive indexes.
B. Gosink,3
and
Dolores
Sonography
H. Pretonius3
were suggestive of adnexal torsion. Laparotomy revealed a hemorrhagic right-sided adnexal mass with 720#{176} torsion of the fallopian tube. A right-sided salpingo-oophorectomy was performed. The final
pathologic
diagnosis
was hemorrhagic
necrosis of the ovary consist-
ent with torsion.
,
Case
Report
A 22-year-old woman (gravida 3, para 2, aborta 1 , last menstrual 5 days before evaluation) had 5 days of increasing pain in the
period right
lower
quadrant
of the abdomen,
examination,
a 7-cm
sonography,
using
right-sided both
nausea, adnexal
and mass
transabdominal
and
vomiting. was
On pelvic
noted.
transvaginal
Pelvic probes,
revealed a well-defined heterogeneous predominantly solid mass in the right adnexa, measuring 5.8 x 8.4 x 7.0 cm (Fig. 1). A moderate amount Pulsed waveform,
of free Doppler with
intraperitoneal evaluation a normal
fluid was the ovarian
of
resistive
index
present artery
of 0.72.
in the showed
cul-de-sac. a normal
Sonographic
findings
Discussion In addition to the case described, we saw two other cases of adnexal torsion with normal Doppler arterial waveforms. These two cases were surgically proved. When adnexal masses are evaluated with Doppler imaging, it is important to evaluate flow within the mass. If Doppler examination is performed near the edge of the adnexal mass, vessels in the pelvic side wall that are unrelated to the ovary may be misinterpreted as reflecting flow to the mass. Vessels in the pelvic side wall anise from the internal iliac artery and have high-resistance waveforms without prominent diastolic flow. It has been theorized that Doppler sonography may facilitate the specific diagnosis of ovarian torsion by revealing lack of blood flow to the ovary. Certainly, color Doppler sonography has been shown to play a decisive role in the diagnosis of testicular torsion in men. It is interesting that in our group of three patients with surgically proved adnexal torsion, all had normal adnexal Doppler arterial waveforms and resistive indexes.
Received February 24, 1992; accepted after revision June 1 6. 1992 I AV, Perez Ponce #492-B, Merida, Yucatan 97000, Mexico. 2 Department of Radiology, Santa Barbara Cottage Hospital, P. 0. Box 689, Santa Barbara, 3 Perinatal Associates of California, 801 0 Frost St., Suite M, San Diego, CA 92123-2788. AJR 159:1251-1253,
December
1992 0361-803X/92/i
596-1251
C American
Roentgen
CA 931 02. Address
Ray Society
reprint
requests
to M. A. Trambert.
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1252
ROSADO
ET AL.
AJR:159,
December
1992
Fig. 1-22-year-old woman who had pain in right lower quadrant for 5 days. Laparotomy revealed 720#{176} torsion of right fallopian tube. A, Transverse transabdominal color Doppler sonogram of twisted right adnexa shows a welldefined mass (M) within ovary, corresponding to clotted blood within a cyst. Many small, welldefined anechoic follicles (arrow) are visible at edge of enlarged ovary, color Doppler signals are seen within ovarian parenchyma and in ovarian artery (arrowhead). B, Pulsed-wave duplex Doppler sonogram of ovarian artery shows a normal waveform, with a normal resistive index of 0.72
Fig. 2-23-year-old
woman who had nausea, vomiting,
and pain in right lower quadrant
for 2 days. Laparotomy
revealed
torsion of right fallopian
A, Coronal transvaginal sonogram shows “solid” component of large, complex, twisted fallopian tube. Pathologically this was found to consist dissecting through fat. Within blood clot, multiple markedly dilated engorged venous channels were found. “Solid” component reveals flow Doppler assessment. B, Pulsed-wave duplex Doppler sonogram shows a normal waveform, with a normal resistive index of 0.67. C, Pulsed-wave duplex Doppler sonogram at edge of cystic component shows a normal waveform, with a normal resistive index of 0.74.
Adnexal torsion occurs predominantly in women of reproductive age. Predisposing factors include nonadherent adnexal masses, found in 50-81 % of patients with adnexal torsion [1 4]. The overall prevalence of torsion as the presenting manifestation of an adnexal mass, most commonly benign cystic teratoma, is 7%. Pregnant women have a greater risk of torsion of adnexal masses than nonpregnant women do. Torsion of a normal ovary is more common in younger females, in whom the adnexa are especially mobile, ,
tube.
of blood by color
allowing torsion at the mesosalpinx [5]. Patients with ovarian hyperstimulation due to treatment with infertility drugs (ovanian hyperstimulation syndrome) who become pregnant have a greater risk of adnexal torsion (i 6%) than do those women who do not become pregnant [2]. Acute changes in intraabdominal pressure, for example from lifting or pushing heavy objects, have been implicated as a factor in adnexal torsion. A spectrum of ischemic changes due to adnexal torsion is noted in the ovary. The amount of damage depends on the
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AJR:i59,
December 1992
SONOGRAPHY
OF
extent of vascular compromise. First, the venous flow and lymphatic return are blocked, along with continued arterial perfusion of the adnexa, leading to diffuse enlargement and edema of the ovarian parenchyma and often to peripheral follicular distension due to transudation of fluid into the cysts. With further passage of time, continued edema and increased pressure on the twisted pedicle will cause venous occlusion followed by arterial thrombosis. Free fluid is found in one third to two thirds of patients. A spectrum of abnormal findings has been identified in patients with adnexal torsion, from massive ovarian edema to ovarian necrosis. Arterial Doppler signals were observed in twisted adnexa in all three of our cases. Possible explanations for these observations include the following: (1) venous thrombosis due to torsion leads to symptoms and ovarian necrosis before arterial thrombosis occurs, and (2) persistent adnexal arterial flow is related to the dual ovarian arterial blood supply (the ovarian artery from the aorta, and the ovarian artery branches from the uterine artery that run in the infundibulopelvic ligament). Despite prior theoretical suppositions of lack of arterial flow
ADNEXAL
TORSION
in adnexal
torsion, arterial Doppler of all three of our patients. larger group of patients, including arterial and venous, is necessary Doppler sonography in the diagnosis adnexa
1253
signal was present in the A prospective study of a examination of flow, both to determine the role of of adnexal torsion.
REFERENCES 1 . Nichols DH, Julian PJ. Torsion of the adnexa. Clin Obstet Gynecol 1985; 28:375-380 2. Mashiach S, Bider D, Moran 0, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990;53:76-80 3. Fleischer AC, Entman 55. Sonographic evaluation of pelvic masses with transabdominal and transvaginal scanning. In: Fleischer AC, Romero R, Manning FA, Jeanty P. eds. The principles andpractice of ultrasonography in obstetrics and gynecology, 4th ed. Norwalk, CT: Appleton & Lange, 1991:537-556 4. Warner MA, Fleischer AC, EdeIl SL, et al. Uterine adnexal torsion: sonographic findings. Radiology i985;154:773-775 5. Graif M, Itzchak Y. Sonographic evaluation of ovarian torsion in childhood and adolescence. AJR i987;150:647-649