[A young woman with acute abdominal pain]

A 21-year-old woman reported to the first aid with acute pain in the right lower abdomen since 5 days, diarrhoea and nausea. There was no fever or muscular guarding, and no signs of inflammation in the blood screening. An ultrasound and a CT-scan of the abdomen showed an ovoid, fatty mass compatible with an appendagitis epiploica. This self-limiting disease does not need treatment.

[Isolated fallopian tube torsion in a teenager--a case report]

Adnexal torsion belongs to the group of urgent cases in gynecology Early diagnosis and management can prevent the loss of an ovary and the Fallopian tube. The case of the 14.5-year-old girl was described by the authors. The symptoms were moderate and caused diagnostics problems. During clinical assessment current literature knowledge, differentiation and treatment of the adnexa were taken into account.

[Torsion of dystopic spleen--possible solutions]

Early diagnosis the torsion of wandering spleen and surgical intervention are necessary to preserve the spleen, because persistant torsion can lead to splenic infarction. We present two cases with torsion of wandering spleen and different disease process and result. Diagnosis was by ultrasonography and CT angiography found. The 7-year-old boy with recurrent abdominal pain was admitted early and operated with spleenpreserving splenopexy. The 8-year-old girl with acute torsion of a wandering spleen was sent of after an initial misdiagnosis too late. Patient was managed by urgent laparotomy and splenectomy, because of splenic vessels thrombosis and splenic infarction. No complications occurred during two year postoperative follow up period of both patients.

A regressive Meigs syndrome after definitive adnexal torsion

The Meigs syndrome is a rare but well known syndrome in which removal of the tumor results in cure. We report a case of a regressive Meigs syndrome after a definitive adnexal torsion which highlights the major role of the vascular phenomena in the physiopathology of this puzzling syndrome.

Torsion of hydatids of Morgagni in premenarchal adolescent girls--a case report and review of literature

Hydatids of Morgagni are very common incidental findings during laparoscopy in women of all age groups. However, torsion of these hydatids is very rarely reported in the literature. This report discusses the importance of considering torsion of hydatids of Morgagni in young adolescent girls who present with acute-onset lower abdominal pain.

Acute abdomen secondary to torsion of Krukenberg tumour

Krukenberg tumour is a rare clinical entity. We report an unusual case of acute abdomen due to right sided adnexal torsion in a 23 year old nulliparous girl with bilateral Krukenberg tumour and primary gastric carcinoma. Possibility of Krukenberg tumour should always be kept in mind while managing ovarian tumours.

[Characteristics of hydronephrosis due to obstruction of the pyeloureteral segment combined with dorsal rotation of the kidney]

Rotation of the kidney is caused by its dystopia and abnormal blood circulation. Dorsal rotation of the kidney in normal position is a rare anomaly. We studied a clinical course, evidence obtained at renosonography, excretory urography, computed tomography, radionuclide investigation, anatomic variants of pyeloureteral segment obstruction in female patients with right-side hydronephrosis in the presence of dorsal rotation of the kidney before and after pyeloplasty. We made pyeloplasty for obstruction of the pyeloureteral segment in 266 patients in 2001-2009. Hydronephrosis was accompanied with dorsal rotation of the kidney in 21 (7.9%) cases. Surgical approaches to the pelviureteral segment are characterized. The dorsal approach is a good alternative to standard subcostal approach, provides good visualization in creation of anastomosis, significantly reduces distance from the skin cut to pyeloureteral segment and offers the best cosmetic result. In subcostal approach mobilization of the pelvis and pyeloureteral segment is preferable on the posterior surface of the kidney. A laparoscopic transperitoneal approach is not justified as it implies wide mobilization of the kidney, the anastomosis is created in extremely limited space.

Isloated tubal torsion in a fourteen year old girl

Isolated torsion of fallopian tube is a rare event and often difficult to diagnose. This report describes such a condition in a patient who presented with pain lower abdomen and underwent laproscopy primarily by surgeons with the suspicion of appendicitis but eventually ended up in right salpingectomy because of isolated right tubal torsion. The issue of future fertility was obviously considered but unfortunately the tube could not be preserved because of necrosis and haemorrhage inside it. Tubal torsion should however be kept in mind in the differential diagnosis of lower abdominal pain in women of all ages.

Tussive syncope in a pug with lung-lobe torsion

The most common presenting clinical signs of lung-lobe torsion include dyspnea, tachypnea, lethargy, and anorexia. Tussive syncope secondary to lung-lobe torsion has not been documented. This article describes the presentation, diagnosis, management, and outcome of a pug with tussive syncope secondary to lung-lobe torsion.

Hydronephrosis of pregnancy associated with torsion of the fallopian tube: a case report

Isolated tubal torsion accompanying pregnancy is an extremely rare condition. Preoperative diagnosis is generally difficult; most of the cases can be diagnosed intraoperatively. Here, we reported a 36-week pregnant with a complaint of acute pain in right lower quadrant that emanating to right lomber region. Abdominal utrasonography showed grade 3 hydronephrosis in right kidney, other findings were normal. A cesarean section was carried out and a twisted right tube were diagnosed. Right ovary was normal in appearance. The torsioned tube compressed the right ureter and caused ureteral dilatation. Right salpingectomy was performed. Postoperative follow-up of the patient was uneventful.

Effect of simple malrotation on percutaneous nephrolithotomy: a matched pair multicenter analysis

PURPOSE

In this multicenter study we compared the outcome of percutaneous nephrolithotomy in patients with and without malrotated kidneys.

MATERIALS AND METHODS

A total of 44 patients (group 1) at 6 institutions who underwent percutaneous nephrolithotomy for kidneys with simple malrotation were enrolled in our study. Attending physicians in our group also provided the same number of cases of percutaneous nephrolithotomy done for nonmalrotated (normal) kidneys (group 2). Group 2 patients were selected by match pairing. Operative and postoperative data on the 2 groups were compared using the chi-square, Student t and Fisher exact tests.

RESULTS

As a result of match pairing, the 2 groups were similar in age, gender, body mass index, and stone size and site. Mean ± SD stone size was 5.9 ± 3.5 cm(2) in group 1. Multiple access attempts were required in 9 (20.5%) and 7 cases (15.9%) in groups 1 and 2, respectively (p >0.05). Mean fluoroscopy time was 7.0 ± 3.9 minutes in the malrotated kidney group and 7.3 ± 4.5 minutes in the nonmalrotated kidney group (p >0.05). The mean hemoglobin decrease after percutaneous nephrolithotomy was significantly higher in group 1 (-1.9 vs -1.3 gm/dl, p = 0.008) but the blood transfusion rate was similar in the 2 groups. The procedure success rate in groups 1 and 2 was 77.3% and 79.5%, respectively (p >0.05).

CONCLUSIONS

Percutaneous nephrolithotomy is safe and effective even in patients with larger kidney stones and malrotated kidneys.

Deliberate posterior low transverse incision at cesarean section of a gravid uterus in 180 degrees of torsion: a case report

BACKGROUND

Torsion of the term gravid uterus is a rare, potentially serious, unexpected obstetric pathology and is almost always diagnosed at cesarean section. We report a case of deliberate posterior low transverse segment hysterotomy in irreducible uterine torsion at 41 weeks' gestation,

CASE

A 29-year-old nullipara with a 15-cm uterine fibroid was admitted at 41 weeks' gestation with regular uterine contractions. Cesarean delivery was carried out for obstructed labor. Intraoperatively, 1800 levotorsion of the uterus was diagnosed. Following unsuccessful attempts at detorsioning the uterus, a posterior low transverse hysterotomy was performed for delivery.

CONCLUSION

Delivery by a posterior low transverse hysterotomy may be feasible in uterine torsion after unsuccessful attempts at detorsioning the uterus during cesarean section at term. (

Uncommon cause of acute abdomen: volvulus of gallbladder with necrosis. Case report and review of literature

Gallbladder volvulus is a rare condition which can mimic an acute cholecystitis. This condition is characterized from a rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Preoperative diagnosis is difficult. This is an acute surgical emergency that must be treated with immediate detorsion and cholecystectomy. We report a case of acute gallbladder torsion in an elderly man and review the clinical aspects of the disease in the context of the available literature.

Tortuous aorta in kyphoscoliosis

We present a rare case of a tortuous aorta in a patient with kyphoscoliosis and the advantages of using radial angiography in this case.

Isolated tubal torsion in pregnancy--a rare case

Isolated fallopian tube torsion is an uncommon cause of acute abdomen in pregnancy. Patients present with lower quadrant abdominal pain, and some have nausea and vomiting. There is no pathognomic diagnostic sign, so most patients are operated when it is too late to save the tube by detorsion alone. Here we present a case of isolated tubal torsion in a term pregnancy managed by salpingectomy and cesarean section simultaneously. As far as we know this will be the 20th case of reported isolated tubal torsion in pregnancy.

[Primary torsion of the omentum majus]

BACKGROUND

Primary torsion of the omentum majus is a rare condition. The clinical picture can mimic other causes of acute abdominal pain. The condition is therefore often not recognised and the diagnosis is made only perioperatively.

CASE DESCRIPTION

A 32-year-old man visited the emergency department with acute abdominal pain. During surgery, the pain turned out to be caused by an ischaemic segment of the omentum majus, resulting in torsion. In retrospect, the patient had been suffering from recurrent attacks of similar abdominal pain for years without a satisfactory diagnosis.

CONCLUSION

In any patient with episodes of recurrent, localised, stabbing abdominal pain, possibly related to exercise and without any other clear diagnosis, the diagnosis 'torsion of the omentum majus' should be considered.

[Torsion of the omentum--an uncommon cause of acute abdomen]

Ometal torsion is a very rare cause of acute abdomen. Its symptoms can mimics acute appendicitis very often. Diagnose can be made only during laparoscopy, or laparotomy, respectively.

Proximal tibial derotation osteotomy for torsional tibial deformities generating patello-femoral disorders

INTRODUCTION

Torsional abnormalities of the leg may cause instability and pain in the patellofemoral joint. Although derotation osteotomies seem logical to address these conditions, there are very few surgical results reported in the literature.

HYPOTHESIS

Isolated tibial derotation osteotomies relieve patellofemoral pain and instability even in the event of combined femoral and tibial torsion abnormalities.

AIM

Test this hypothesis in a retrospective and continuous series of thirty-six tibial derotation osteotomies and define the factors of success and failure.

PATIENTS AND METHODS

Thirty-six derotation osteotomies of the proximal tibial metaphysis were performed between 1995 and 2006 in 29 patients (five men and 24 women, an average of 26.5 years old±7.4 (18-44)) followed-up for a mean 4.7 years. There was confirmed patellar instability in five knees, and patellofemoral pain without instability in 31. A proximal metaphyseal osteotomy was performed to correct excessive external tibial rotation as well as to recenter the tibial tubercle after anterior tibial cortex elevation. All patients were followed-up and the clinical data were analysed according to criteria from the Lille score [specifically designed for patellofemoral joints (100 point score)] and the IKS score. All patients had a preoperative radiological evaluation [(including measurement of torsion abnormalities in 32 cases by computed tomodensitometry (CT scan))]. The mean preoperative external tibial torsion measured on CT scan was 36.2°±9.48 (26-51°) and the mean femoral anteversion was 19.4°±9.5 (8-36°).

RESULTS

Twenty-seven patients (94%) were satisfied or very satisfied. The Lille score increased from 54.8±16.9 (30-92) preoperatively to 85.2±14.2 (36-100) at follow-up. The mean IKS knee scores and function increased from 56±14.8 (45-94) to 94±12.1 (60-100) and from 71±18.4 (30-100)-96±11.9 (50-100). Patellofemoral dislocations did not occur in any of the five cases with instability. Mean derotation was 25° measured with a mean tibial torsion measured clinically at follow-up 8.6°±7.2 (0-30). Two reoperations were necessary, (one knee manipulation under general anesthesia, and in another the fibular fibrous arch had to be released). One case of regressive palsy of the common fibular nerve was observed. Union of the osteotomy was obtained in all patients.

DISCUSSION

This series is one of the largest series published to date. Isolated medialization of the anterior tibial tubercle only partially corrects these morphological abnormalities. In cases of associated excessive femoral anteversion we recommend surgery to the tibia alone because results were comparable in groups with and without excessive anteversion of the femoral neck.

LEVEL OF EVIDENCE

level IV. Retrospective study.

Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion

OBJECTIVE

Adnexal torsion is a common gynecologic emergency affecting females of all ages. Expedient diagnosis and treatment are important, particularly in young fertile patients to preserve ovarian viability. Classical parameters for the clinical and sonographic diagnosis of adnexal torsion have very high false-positive rates, approaching 50%. The sonographic 'whirlpool' sign has been shown to be effective for visualizing the torsed part in the prenatal diagnosis of malrotation of the midgut with volvulus, as well as scrotal and ovarian torsion. We aimed to evaluate the efficacy of the whirlpool sign in the diagnosis of torsion, as compared to a protocol based on 'classic' sonographic signs of torsion alone.

METHODS

This was a retrospective chart review. Files of all patients who underwent laparoscopy for suspected torsion at our center between January 2006 and May 2009 were extracted and reviewed. Ultrasound reports were retrieved from our computerized database. Patients were assigned to the study group if the whirlpool sign had been investigated during pre-procedural evaluation or to the control group if only the standard protocol had been applied.

RESULTS

Eighty women were referred for laparoscopy for suspected adnexal torsion during the study period. In 22 women the ultrasound investigation had included the whirlpool sign (study group) while 58 had been examined by the standard protocol (control group). Twenty women in the study group had a positive whirlpool sign on ultrasound, 18 of whom (90.0%) had confirmed torsion on laparoscopy. In the control group 32 of 58 (55.2%) women had confirmed torsion on laparoscopy.

CONCLUSION

The addition of the sonographic whirlpool sign to the preoperative sonographic evaluation of patients with suspected torsion appears to improve the rate of true-positive diagnoses as confirmed by laparoscopy. Copyright © 2010 ISUOG. Published by John Wiley & Sons, Ltd.

Twists and turns in the body: an imaging spectrum

Life is full of twists and turns. These surprises can sometimes be wonderfully invigorating. Twists and turns can also occur in the body, however, sometimes with dangerous consequences. Torsion and volvulus are important causes of acute abdominal pain. The clinical symptoms and signs associated with torsion and volvulus are often non-specific and are difficult to diagnose clinically. Clinicians frequently rely on imaging methods to make the diagnosis. Prompt and accurate diagnosis is important to avoid the life-threatening complications of torsion and volvulus. Therefore, it is helpful to be familiar with the features of torsion and volvulus.

Torsion of the omentum. A rare cause of acute abdomen

OBJECTIVE

To describe the clinical aspects, treatment and evolution of acute abdomen caused by torsion of the greater omentum.

METHODS

Retrospective analysis study consisted of a group of eleven patients with acute abdomen caused by torsion of the greater omentum. The variables included were age, sex, body mass index (BMI), clinical picture, evolution time, laboratory tests, radiology and treatment. Descriptive statistical analysis was employed.

RESULTS

Seven (63.6%) women and four (36.36%) men; mean age 33 (20 to 58) years; BMI > 25.0 in nine (81.81%); average evolution 6.54, SD 3.47 days. All presented abdominal pain, six (54.5%) abdominal distension, four (36.3%) walking difficulty, three (27.27%) general malaise, ten (90.9%) slight leucocytosis, five (45.4%) previous surgery. In all cases diagnosis was made by laparotomy, treatment was resection of the affected segment, and no complications were seen.

CONCLUSIONS

Segmental torsion of the greater omentum is a rare cause of acute abdomen. Pain is the most frequent symptom, and the condition resembles acute appendicitis. It is often discovered during surgery and is treated by the removal of the affected omentum segment.

A case of splenic torsion with progressive anemia and thrombocytopenia

A 4-year-old male, castrated Saint Bernard was evaluated for acute onset of lethargy and collapse. Moderately severe anemia and splenomegaly were noted. Immune mediated hemolytic anemia was initially suspected. Abdominal ultrasound demonstrated an absence of splenic blood flow. Splenic torsion was confirmed on exploratory laparotomy and a splenectomy was performed.