Isolated torsion of fallopian tube during pregnancy; report of two cases

Isolated torsion of fallopian tube is very uncommon during pregnancy. Predisposing factors for torsion are hydrosalpinx, prior tubal operation, pelvic congestion, ovarian and paraovarian masses and trauma. Although the most important clinical symptom is abdominal pain in lower quadrants, the diagnosis is usually established during the operation performed for acute abdomen and salpingectomy is almost always necessary. Two cases of torsion of fallopian tube during pregnancy, one with hydrosalpinx, the other with paratubal cyst are presented and symptoms and predisposing factors are discussed.

Scrotal pathology as the cause for hip pain. Diagnostic findings on bone scintigraphy

Scrotal scintigraphy has become a relatively uncommon examination in many nuclear medicine departments. However, scrotal perfusion is visualized during three-phase bone imaging of the pelvis and hips. The authors present a compilation of three cases of hip pain secondary to unsuspected scrotal pathology documented on routine three-phase bone scintigraphy, discussing this topic for the first time in the literature. A short review of the pathophysiology of referred hip pain, differential diagnosis, and imaging alternatives emphasize the unique contribution of nuclear imaging.

Contrast-enhanced ultrasonographic visualization of gonadal torsion

The purpose of this study was to investigate the effect of use of intravenous ultrasonographic contrast agent in the diagnosis of gonadal torsion in an animal model. After examination of perfusion of normal gonads in male and female dogs, torsion was produced and maintained mechanically. Presence and pattern of blood flow was then reassessed before and after administration of varying doses of perfluorocarbon-filled microsphere intravenous contrast agent. Modes of examination included gray scale, color flow, color power, and spectral analysis using a transducer placed directly on the surgically exposed gonads. Although no enhancement was perceptible on gray scale images, color and spectral Doppler signals were significantly stronger after injection of contrast agent in both normal and rotated gonads. Perfusion asymmetry was more obvious. Some residual flow was seen in partially rotated testes, and absence of flow was documented in both partially and fully rotated ovaries. Use of intravenous contrast medium improves demonstration of altered flow patterns in ischemic gonads, allowing more confident diagnosis.

[Adnexal torsion in children: plea for early laparoscopic diagnosis and treatment]

BACKGROUND

Experience with adnexa torsion in children, a rare but potentially severe pathology, is still disappointing despite constant radiological progress.

PATIENTS AND METHODS

The files of 19 patients with adnexial torsion treated between 1985 and 1995 were retrospectively reviewed and compared to those reported.

RESULTS

Eight adnexectomies, six oophorectomies, five detorsions with cystectomy and one salpingectomy were performed. There were only five salvaged adnexa in this series. Three tumors were found; all other cases, except three, were torsions induced by voluminous functional cysts.

DISCUSSION AND CONCLUSION

Clinical context (sudden right pelvic pain without fever) seems important to note. Sonographic examination is first necessary, but its results are not accurate enough to confirm the torsion. Endo-rectal ultrasonography should become the best diagnostic method in cases of complicated ovaries. In order to increase the percentage of salvaged adnexa, the authors recommend a laparoscopic approach in emergency when clinical examination was doubtful.

Lung torsion--a rare postoperative complication. A case report

Lung or lobe torsion is a rare condition that must be included in the differential diagnosis when a partial or complete shadow is detected on the lung. We report a case of this rare complication after chest surgery. The bedside radiograph provided initial evidence of torsion. CT verified the diagnosis of lower lobe torsion. Prompt recognition and intervention is imperative in order to save the affected lung.

Large torsed neonatal ovarian cysts associated with massive vesicoureteral and intrarenal reflux

The cases of two infants with large neonatal ovarian cysts complicated by salpingotorsion are reported. Both had persistent hydronephrosis after resolution of the ovarian cyst. Voiding cystourethrography in each child demonstrated massive vesicoureteral reflux with intrarenal reflux. The potential significance of this association and its possible cause are discussed.

Ultrasound biomicroscopic findings of acute angle-closure glaucoma in Vogt-Koyanagi-Harada syndrome

PURPOSE

We studied a case of Vogt-Koyanagi-Harada syndrome with transient shallow anterior chamber and increased intraocular pressure as initial manifestations.

METHODS

We examined the patient using ultrasound biomicroscopy and speculated on the mechanisms of increased intraocular pressure.

RESULTS

Ultrasound biomicroscopic examinations revealed the swollen ciliary body with anterior rotation and supraciliary space at the time of increased intraocular pressure.

CONCLUSIONS

We confirmed that the swollen ciliary body with anterior rotation and supraciliary space caused transient angle-closure glaucoma in this patient with Vogt-Koyanagi-Harada syndrome.

Distal ileocolic intussusception: another cause of inversion of superior mesenteric vessels in infants

OBJECTIVE

Inversion of the superior mesenteric vessels is associated with various conditions. The purpose of this study was to prospectively evaluate the position of these vessels in infants with idiopathic ileocolic intussusception.

SUBJECTS AND METHODS

Abdominal sonography was performed before and after reduction of ileocolic intussusception in 16 infants.

RESULTS

In 14 infants with ileocolic intussusception proximal to the splenic flexure, the relationship of the superior mesenteric vessels was normal (superior mesenteric vein to the right ventral side of superior mesenteric artery). Inversion of the superior mesenteric vessels (superior mesenteric vein to the left of the superior mesenteric artery) was found in two patients with distal ileocolic intussusception (head of the intussusceptum at the sigmoid colon or rectum). After reduction, the relationship of these vessels was normal in all 16 infants.

CONCLUSION

Inversion of the superior mesenteric vessels is sometimes caused by distal ileocolic intussusception in infants.

[A case of right upper lobe carcinoma with lung torsion changed in position]

A 71-year-old man with a pulmonary carcinoma had torsion of the right upper lobe of the lung. A chest radiogram showed change of the opacified lobe in position. At right thoracotomy, we found that the atelectatic right upper lobe occupied with a giant tumor moved freely in the right thoracic cage due to the defect of parenchymal bridge between the contiguous lobes. Though lung torsion is a rare event, it might be kept in mind as a complication of malignant tumors or life-threatening lung infarctions.

Computed tomographic appearance of sigmoid volvulus

The computed tomographic (CT) appearance of two cases of sigmoid colon volvulus is described. Both underwent plain abdominal radiographs, contrast enema, and CT. The findings of sigmoid volvulus at CT were characteristic, having a whirl pattern of the dilated sigmoid loop around mesocolon and vessels and a bird-beak aspect of the afferent and efferent segments. CT may be valuable in a case of unusual clinical or plain film presentation as an alternative to contrast enema.

Fetal ovarian torsion appearing as a solid abdominal mass

Fetal and neonatal ovarian cysts can be small asymptomatic lucencies or large symptomatic echocomplex masses that can cause intestinal obstruction and peritonitis. Solid masses are the most rare form of ovarian cysts. A fetus, anatomically unremarkable at 16 weeks' development, was found at 35 weeks to have a 5 x 5 cm solid mass. After delivery a laparotomy was performed, and a torsed ovary measuring 8 x 7 cm was removed. The infant did well after the procedure. Over 400 cases of perinatal ovarian cysts have been reported in the literature. Only 1% of these are purely echodense. When a fetal abdominal mass is present, separate from bowels and kidneys, a torsed ovary should be considered in the differential diagnosis. Management of the pregnancy and infant may be guided by the fetus or neonate's symptoms.

Color Doppler sonography of tubal torsion

These case reports illustrate the clinical and color Doppler sonographic findings in two cases of isolated tubal torsion. This condition may be associated with prior tubal ligation. The presence of high impedance or absent flow in a tubular structure in a patient with a history of tubal ligation should make one suspect this condition.

Computed tomographic enteroclysis: one methodology

RATIONALE AND OBJECTIVES

Computed tomography (CT) is limited in the assessment of partial small bowel obstruction (SBO). Enteroclysis is preferred but gives little direct information about the bowel wall, mesentery, or remote findings. Preliminary results of a combined CT enteroclysis (CT-E) methodology are reported.

METHODS

Forty-eight patients with suspected partial SBO underwent a water soluble contrast enteroclysis followed immediately by CT. Pump rates at fluoroscopy and CT were 75 to 100 cc/min unless a high-grade obstruction was encountered at fluoroscopy. Shrake's criteria for complete, high-grade or low-grade partial SBO were used.

RESULTS

The calculated dose per patient was 27 rad for CT-E as opposed to 32 rad with traditional enteroclysis. Site specific sensitivity and specificity for low-grade partial SBO, were 82.1% and 87.5%. One death was encountered in a patient with diffuse abdominal metastatic disease and complete obstruction. This was caused by vomiting and aspiration secondary to tube placement alone, CT-enteroclysis having been aborted.

CONCLUSIONS

Computed tomographic enteroclysis is a diagnostic option for evaluation of low-grade partial SBOs. Pitfalls with this technique are encountered in decompressed torsions and hernias.

Intravascular gas within an ovarian tumor: a CT sign of ovarian torsion

A case of twisted ovarian tumor with intravascular gas is presented, and the mechanism of the gas formation is discussed. On the basis of the probable mechanism of gas formation observed in dead fetuses, the gas seen in the present case is considered to have been oxygen released from trapped oxyhemoglobin within the tumor vessels. "Intravascular gas" within an ovarian tumor, although extremely rare, is diagnostic of ovarian torsion.

Automobile-induced obstruction of the intrathoracic caudal vena cava in a dog

A two-year-old labrador retriever was examined after a year's history of persistent ascites and exercise intolerance that began shortly after the dog was struck by an automobile. Contrast venography showed tortuosity of the intrathoracic caudal vena cava with partial obstruction caused by kinking of the vessel. Surgical resection of a fibrous connective band that was found to be tethering the intrathoracic vena cava ventrally, creating a partial obstruction, was performed. A hypothesis of the aetiology of this phenomenon is presented.

Color Doppler sonography of adnexal torsion

The purpose of this study was to describe the color Doppler sonographic findings in adnexal torsion that distinguish viable from nonviable ovaries. We present the color Doppler sonographic features in 13 patients with surgically proved adnexal torsion that help determine whether or not the ovaries were viable or nonviable at the time of surgery. Eleven combined ovarian and tubal torsions and two isolated tubal torsions were studied. In 10 cases the ovaries were considered nonviable at the time of surgery and in three cases they were considered viable. Of the nonviable group, six showed absent arterial and venous flow centrally, but two had low velocity (< 5 cm/s) arterial flow peripherally in the region of the adnexal branch of the uterine artery or in the main ovarian artery, and two demonstrated absent or reversed diastolic arterial flow. None of the nonviable ovaries showed venous flow centrally. In contrast, all of the viable ovaries demonstrated venous flow centrally, and two had peripheral and central arterial flow. Although the CDS findings in adnexal torsion are variable, ovarian viability may be predicted if central venous flow is present.

[Acute torsion of hydrosalpinx. 2 cases after laparoscopic sterilization]

We report on two laparoscopically sterilised patients who presented with increasing lower abdominal pain and sonographically proven adnexal masses. The first patient, who had been sterilised two years ago, underwent primary laparotomy. The mass was found to correspond to the cystically altered distal part of the right sterilised tube being torquated twice. Standard salpingectomy was performed. On the second patient, sterilised ten years before presentation at our clinic, we performed laparoscopy because of the suspected diagnosis of a pyosalpinx. In this case we found a torsion of the ampullary part of the left tube, which was subsequently removed by laparoscopy.

Ovarian torsion in prepubertal and pubertal girls: sonographic findings

OBJECTIVE

The purpose of this study is to report the range of gray-scale and color Doppler findings of ovarian torsion in prepubertal and pubertal girls to determine whether there is a difference in appearance between the two age groups.

MATERIALS AND METHODS

The study population consisted of 20 patients, 11 who were prepubertal (ages 2 days to 6 years) and nine who were pubertal (ages 12-16 years), who had gray-scale sonograms and surgical confirmation of ovarian torsion. Color Doppler studies were obtained in 14 of 20 patients. All sonograms were reviewed retrospectively by two radiologists with attention to location of the twisted ovary, internal characteristics, and evidence of color Doppler flow. The results were then compared in the prepubertal and pubertal groups.

RESULTS

Sonographic findings of torsion in 11 prepubertal patients included complex mass with septations and debris (6/11), cystic mass (1/11), and solid mass with peripheral cysts (4/11). The masses were located in the right lower quadrant (5/11), left lower quadrant (3/11), right adnexa (2/11), and right inguinal canal (1/11). Eight of nine pubertal patients had solid masses, and one had a thick-walled cystic mass. Torsion involved the right ovary in nine patients and the left in 11. Color patterns included central flow (3/14), peripheral flow (6/14), and absence of flow (5/14) and did not correlate with age or gray-scale findings.

CONCLUSION

Sonographic findings of ovarian torsion vary with age. Neonates and young children have extrapelvic cystic or complex cystic masses, whereas pubertal girls have predominantly solid masses in an adnexal location. In both groups of patients, color Doppler signal can be documented in many twisted ovaries.

Ovarian torsion: diagnosis by color Doppler ultrasonography

BACKGROUND

Ovarian torsion, although a rare gynecologic emergency, is a threat to women of all ages. Traditionally, ultrasonography and laparoscopy facilitated early diagnosis and treatment of this condition. This case report highlights the usefulness of color Doppler ultrasonography in the diagnosis of ovarian torsion.

CASE

A 25-year-old patient who conceived after ovulation induction was treated conservatively for mild ovarian hyperstimulation and threatened abortion. She subsequently underwent selective first-trimester multifetal reduction and was admitted and treated for suspected pelvic infection. On the 17th post-procedure morning, ovarian torsion was diagnosed using color Doppler ultrasonography.

CONCLUSION

Because gynecologists face serious management dilemmas when confronted with ovarian torsion, this technique of using color Doppler ultrasonography should provide a highly specific finding in complete ovarian torsion, aiding the clinician in prompt diagnosis and treatment.

Torsion of pedunculated hepatocellular carcinoma. Report of a case in a young woman presenting with abdominal pain

Pedunculated Hepatocellular Carcinoma is an extremely rare neoplasm. There are less than 30 documented cases in the world literature. We present a case which was diagnosed preoperatively using abdominal CT scan and angiography. The fact that the pedunculated tumor had undergone torsion with some necrosis precipitated symptoms of abdominal pain. This is the first reported case of this rare tumor presenting with torsion.

Wandering spleen with torsion: appearance on CT and ultrasound

Wandering spleen is a rare entity which may present with symptoms suggestive of other, more common abdominal processes. Torsion of the long pedicle may occur causing abdominal pain. This article describes a case of wandering spleen diagnosed by computed tomography (CT). Liver spleen scintigraphy and sonography supported this diagnosis and suggested torsion. To our knowledge this is only the second case of this entity in which color flow and duplex Doppler findings have been reported.

CT in adnexal torsion with emphasis on tubal findings: correlation with US

OBJECTIVE

Our goal was to determine the CT and US aspects of the fallopian tube in adnexal torsion.

MATERIALS AND METHODS

The CT scans and US studies of 10 patients with surgically proven unilateral torsion of the adnexa were reviewed.

RESULTS

On CT the fallopian tube on the involved side was identified in eight cases as an almost tubular or comma-shaped structure extending from the uterine cornua and covering partially the adnexal mass. This tube was significantly thickened and measured 20-40 mm. Hemorrhage (density > or = 50 HU on precontrast CT scans) was present in the tube in six patients. A heterogeneous contrast agent uptake was detected in the tube in five patients. An adnexal mass was visualized on the involved side in all patients, with hemorrhage in the mass in four patients. Peritoneal fluid and/or ileus were present in six patients. On US an echogenic structure that corresponded to the enlarged tube visualized on CT was detected in three cases and an adnexal mass in all cases.

CONCLUSION

Thickening of the fallopian tube with hemorrhage could be detected by CT and is suggestive of torsion especially if associated with an adnexal mass.

Transabdominal color Doppler ultrasonography of the painful adolescent ovary

The objective of this study was to determine if color flow Doppler ultrasonography based on patterns of perfusion can aid in providing a specific diagnosis of ovarian masses associated with pelvic pain. Color flow Doppler images of 42 ovarian lesions in 42 adolescent girls (age range, 10 to 17 years) were analyzed prospectively. The color flow patterns were classified into three main categories: lesions with no vascularity; lesions with peripheral vascularity; and lesions with internal vascularity. The diagnoses included 22 hemorrhagic ovarian cysts, seven simple cysts, three cystadenomas, seven inflamed ovaries (five with microabscesses and two with dominant cystic abscesses), and three ovarian torsions. A peripheral pattern of flow was observed in 29 of 34 (85%) cystic lesions, including 18 hemorrhagic and six simple cysts, three cystadenomas and two abscesses. Peripheral flow was also identified in four enlarged ovaries, two with inflammatory disease and two with torsion. Internal flow was noted in five patients with enlarged ovaries due to inflammatory disease. Intraovarian flow was absent in three patients with torsion and in five of 34 cystic lesions. Internal ovarian flow was identified in 90% of normal ovaries. Resistive indices, obtained in 33 abnormal ovaries, were higher in cystic lesions than in inflammatory lesions, although the values overlapped. Our findings showed that internal ovarian flow can be found in inflammatory processes and normal ovaries, but the absence of flow also is nonspecific and can be found in a variety of ovarian cystic lesions as well as in torsion. This overlap limits the usefulness of color Doppler ultrasonography for differentiating cystic ovarian lesions associated with pain in adolescent girls.

Torsion of accessory fallopian tube: ultrasound findings in two premenarchal girls

The ultrasound findings of two cases of fallopian tube duplication, both of which had undergone torsion, are described. Two premenarchal girls were examined with ultrasound because of clinical evidence of pelvic pathology. Both were found to have complex cystic structures that on surgery and subsequent pathological examination were shown to be twisted accessory fallopian tubes. Accessory fallopian tubes have been reported to occur in 6-13% of selected patient groups. To our knowledge, torsion of an accessory tube has not been reported in the literature.

[Computed tomographic torsion-angle and length measurement of the lower extremity. The methods, normal values and radiation load]

Complex corrective osteotomies in the lower extremities require precise preoperative planning. Fifty patients (37 male, 13 female) with an average age of 31 years (13 to 61 years) who had suffered fractures of the lower limbs and had been treated by osteosynthetic or conservative methods were studied, using a GE 9800 Quick CT; accurate and reproducible measurements of the angles of torsion of the femur and tibia were obtained. Digital images were produced to standardise the planes of measurement and to measure the length of the limb. The normal extremities of patients older than 18 years showed internal torsion of -20.4 +/- 9 degrees of the femur and external torsion of 33.1 +/- 8 degrees of the tibia. The most important clinical measurement is the intra-individual difference of the torsional angles. Amongst normals this is 4.3 +/- 2.3 degrees in the femur and 6.1 +/- 4.5 degrees in the tibia. Consequently, only angles greater than 9 degrees in the femur and 15 degrees in the tibia should be regarded as abnormal. Radiation exposure was measured by a LiF-thermoluminescence dosimeter on an Alderson phantom. Skin dose was 6.3 +/- 1.2 mGy and gonadal dose for females was 2.5 +/- 0.3 mGy and for males 0.7 +/- 0.1 mGy.

Appendices epiploicae of the colon: radiologic and pathologic features

Appendices epiploicae are adipose structures protruding from the serosal surface of the colon. They can be seen with abdominal radiography and cross-sectional imaging if the colonic wall is surrounded by intraperitoneal contrast material, ascites, or blood. Normal appendices epiploicae appear as lobulated masses of pericolic fat, usually 2-5 cm long and 1-2 cm thick. Their enlargement, deformity, or altered radiopacity may result from various pathologic processes that can originate locally or extend from adjacent viscera. In a series of 22 cases, appendices epiploicae were affected by spontaneous torsion and hemorrhagic infarct, calcification due to aseptic fat necrosis, primary or secondary inflammation, enlargement by lipomas or metastases, and incarceration in hernias. Disorders of appendices epiploicae are often manifested by nonspecific clinical signs and symptoms (eg, torsion is often mistaken for appendicitis or diverticulitis). These entities should be included in the differential diagnosis of any unexplained abdominal pain or pericolic lesions in adults.

Midgut malrotation, the reliability of sonographic diagnosis

We are unaware of any other anatomical study which deals with normal variations in the relationship between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). In our investigation in the majority of cases, the SMV lies to the right of the SMA. It has been suggested that ultrasonographic demonstration of a left sided SMV, is characteristic of midgut malrotation so a prospective study was undertaken in order to try to correlate the position of the mesenteric vessels on Ultrasound with the radiological diagnosis of midgut malrotation on upper GI series. 427 children (95% infants) who were planned for upper GI investigation, have had color Doppler U.S. of the mesenteric vessels before the barium study. In 67 cases, the mesenteric vessels were obscured by intestinal gas. Among them, there were 2 cases of malrotation. Three different positions of the mesenteric vessels were found in the 360 remaining cases. 1) A left sided SMV was found in 4% of the cases, all had midgut malrotation on X-rays and at surgery. 2) A mesenteric vein anterior to the SMA was found in 5% of the cases, 28% had midgut malrotation. 3) A normal right sided SMV was found in 91% of the cases. However 3% of these had midgut malrotation. There are anatomical variations in the position of the mesenteric vessels and a normal relationship between SMA and SMV does not exclude the possibility of intestinal malrotation. Nevertheless, ultrasound remains a useful noninvasive screening technique for the diagnosis of midgut malrotation.

Ultrasound diagnosis of midgut volvulus: the "whirlpool" sign

The authors present their US findings in 24 patients with proved complicated midgut malrotation: volvulus in 18 and occlusive Ladd's bands in 6. All the 24 patients have had US examination prior to surgery. Contrast examinations were performed in only 9 patients, always after US and before surgery. The sonographic "whirlpool" pattern of the superior mesenteric vein and mesentery around the superior mesenteric artery was detected in 15 of the 18 patients with midgut volvulus, and was best seen using Doppler color. Embryological signification of midgut malrotation is discussed.

[Axis-related spontaneous correction after tibial fractures in childhood]

In the Department of Surgery at the Bergmannsheil University Hospital, a total of 50 children with measurable post-traumatic deformity of the axis after fracture of the lower limb were examined. Clinical and radiological monitoring was carried out 6 years after their accidents, which they had sustained at the age of 3-15 years. The real degree of axis deformity remaining was determined mathematically, and the correction tendency was analysed in three dimensions and projected graphically using sum vectors. This showed better results in the correction of axis deformations of the lower limb visualized on a-p X-ray photographs as varus or valgus than of deformations seen as ante- and recurvation of lateral X-ray photographs. The excentric arrangement of muscles in the dorsal part of the lower limb could be one reason for this. All 50 patients experienced a reliable spontaneous correction of the axis deformity with no complications of stimulatory growth disturbance with showing good functional results. Shaft fractures of the lower limb in children are generally treated conservatively, operative treatment being indicated only in the case of severe lesions of the soft tissue and in adolescent patients.