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Brook OR, Dadour JR, Robbins JB, Wasnik AP, Akin EA, Borloz MP, Dawkins AA, Feldman MK, Jones LP, Learman LA, Melamud K, Patel-Lippmann KK, Saphier CJ, Shampain K, Uyeda JW, VanBuren W, Kang SK. ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update. J Am Coll Radiol 2024; 21:S3-S20. [PMID: 38823952 DOI: 10.1016/j.jacr.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Joseph R Dadour
- Research Author, Centre Hospitalier de l'Université de Montréal, Montréal, Montreal, Quebec, Canada
| | | | - Ashish P Wasnik
- Panel Vice Chair, University of Michigan, Ann Arbor, Michigan
| | - Esma A Akin
- The George Washington University Medical Center, Washington, District of Columbia; Commission on Nuclear Medicine and Molecular Imaging
| | - Matthew P Borloz
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Emergency Physicians
| | | | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Kira Melamud
- New York University Langone Health, New York, New York
| | | | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Jennifer W Uyeda
- Brigham & Women's Hospital, Boston, Massachusetts; Committee on Emergency Radiology-GSER
| | | | - Stella K Kang
- Specialty Chair, New York University Medical Center, New York, New York
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2
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Taylor M, Gallegos M. A case of acute onset right lower quadrant abdominal pain. J Am Coll Emerg Physicians Open 2024; 5:e13104. [PMID: 38298477 PMCID: PMC10829684 DOI: 10.1002/emp2.13104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Affiliation(s)
- Michael Taylor
- Department of Emergency MedicineStanford School of MedicineStanfordCaliforniaUSA
| | - Moises Gallegos
- Department of Emergency MedicineStanford School of MedicineStanfordCaliforniaUSA
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3
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Higashide R, Tsukada T, Ichikawa M, Sakamoto M, Shimabukuro K. Ovarian torsion due to ovarian hyperstimulation syndrome diagnosed by sonographic whirlpool sign in the first trimester of pregnancy: A case report. Radiol Case Rep 2023; 18:3386-3389. [PMID: 37502479 PMCID: PMC10369376 DOI: 10.1016/j.radcr.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
Ovarian torsion during pregnancy is a rare condition that needs prompt diagnosis and detorsion in order to preserve ovarian function. Diagnosing ovarian torsion is a difficult procedure especially in pregnant cases since radiation exposure should be avoided. Detecting the whirlpool sign by ultrasonography is a highly useful technique as it is noninvasive, less time-consuming, and radiation-free. Here is a case of ovarian torsion due to ovarian hyperstimulation syndrome diagnosed solely by sonographic features and in which laparoscopic detorsion was promptly performed. A 26-year-old woman in her sixth week of pregnancy visited a tertiary hospital with sudden onset lower abdomen pain. Transvaginal ultrasound detected an 8 cm left ovary and a whirlpool sign between the uterus and left ovary. Ovarian torsion was suspected and laparoscopic surgery was performed. Intraoperatively, an enlarged left ovary was twisted at 540° involving the left fallopian tube. After detorsion, bilateral ovaries were preserved and the postoperative course was uneventful. Ovarian torsion was suspected solely by ultrasonographic features which led to surgical detorsion quickly, resulting in the preservation of bilateral ovaries. Detecting the whirlpool sign when ovarian torsion is suspected is useful, especially in pregnant women.
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Higashide R, Saito K, Hashido N, Ishikawa T, Miyasaka N. Step-by-step instructions for detecting whirlpool sign in adnexal torsion. J Rural Med 2023; 18:189-193. [PMID: 37448699 PMCID: PMC10336344 DOI: 10.2185/jrm.2023-002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/11/2023] [Indexed: 07/15/2023] Open
Abstract
Objective: Adnexal torsion is a common gynecological emergency whose prompt diagnosis is essential because a delay may lead to ovarian dysfunction. Although the whirlpool sign is reliable for diagnosing ovarian cyst torsion, technical difficulties hinder its use by sonographers. Here we developed a systematic approach to visualizing this sign by focusing on the fact that torsion arises from the space between the uterus and the pelvic wall. One must determine the origin of the torsion via transverse imaging of the uterus and follow the twisted ligaments to the ovarian cyst. Patients and Methods: Two women aged 56 (Case 1) and 28 years (Case 2) visited our hospital with lower abdominal pain. Transvaginal ultrasonography showed a 7-cm right ovarian cyst in Case 1 and a 5-cm cyst in the Douglas pouch in Case 2; normal bilateral ovaries and the whirlpool sign were detected in both cases. Under laparoscopic guidance in Cases 1 and 2, an ovarian cyst and a paraovarian cyst were confirmed and removed. Results: Our step-by-step method allowed us to identify the whirlpool sign and confirm adnexal torsion, leading to prompt surgery in both cases. Conclusion: Using a systematic procedure helps less experienced practitioners detect the whirlpool sign.
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Affiliation(s)
- Ryo Higashide
- Department of Obstetrics and Gynecology, Tsuchiura Kyodo
General Hospital, Japan
- Department of Comprehensive Reproductive Medicine, Graduate
School, Tokyo Medical and Dental University, Japan
| | - Kazuki Saito
- Department of Perinatal and Maternal Medicine (Ibaraki),
Graduate School, Tokyo Medical and Dental University, Japan
| | - Nanako Hashido
- Department of Comprehensive Reproductive Medicine, Graduate
School, Tokyo Medical and Dental University, Japan
| | - Tomonori Ishikawa
- Department of Perinatal and Maternal Medicine (Ibaraki),
Graduate School, Tokyo Medical and Dental University, Japan
| | - Naoyuki Miyasaka
- Department of Comprehensive Reproductive Medicine, Graduate
School, Tokyo Medical and Dental University, Japan
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5
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Garde I, Paredes C, Ventura L, Pascual MA, Ajossa S, Guerriero S, Vara J, Linares M, Alcázar JL. Diagnostic accuracy of ultrasound signs for detecting adnexal torsion: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:310-324. [PMID: 35751902 DOI: 10.1002/uog.24976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy of different ultrasound signs for diagnosing adnexal torsion, using surgery as the reference standard. METHODS This was a systematic review and meta-analysis of studies published between January 1990 and November 2021 evaluating ovarian edema, adnexal mass, ovarian Doppler flow findings, the whirlpool sign and pelvic fluid as ultrasound signs (index tests) for detecting adnexal torsion, using surgical findings as the reference standard. The search for studies was performed in PubMed/MEDLINE, CINAHL, Scopus, The Cochrane Library, ClinicalTrials.gov and Web of Science databases. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to evaluate the quality of the studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios were calculated separately, and the post-test probability of adnexal torsion following a positive or negative test was also determined. RESULTS The search identified 1267 citations after excluding duplicates. Eighteen studies were ultimately included in the qualitative and quantitative syntheses. Eight studies (809 patients) analyzed the presence of ovarian edema, eight studies (1044 patients) analyzed the presence of an adnexal mass, 14 studies (1742 patients) analyzed ovarian Doppler flow, six studies (545 patients) analyzed the whirlpool sign and seven studies (981 patients) analyzed the presence of pelvic fluid as ultrasound signs of adnexal torsion. Overall, the quality of most studies was considered to be moderate or good. However, there was a high risk of bias in the patient-selection and index-text domains (with the exception of the whirlpool sign) in a significant proportion of studies. Pooled sensitivity, specificity, and positive and negative likelihood ratios of each ultrasound sign were 58%, 86%, 4.0 and 0.49 for ovarian edema, 69%, 46%, 1.3 and 0.67 for adnexal mass, 65%, 91%, 7.6 and 0.38 for the whirlpool sign, 53%, 95%, 11.0 and 0.49 for ovarian Doppler findings and 55%, 69%, 1.7 and 0.66 for pelvic fluid. Heterogeneity was high for all analyses. CONCLUSIONS The presence of an adnexal mass or pelvic fluid have poor diagnostic accuracy as ultrasound signs of adnexal torsion, while the presence of ovarian edema, the whirlpool sign and decreased or absent ovarian Doppler flow have good specificity but moderate sensitivity for detecting adnexal torsion. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I Garde
- Department of Obstetrics and Gynecology, Hospital Universitario de Cruces, Bilbao, Spain
| | - C Paredes
- Department of Obstetrics and Gynecology, Hospital Materno-Infantil, Badajoz, Spain
| | - L Ventura
- School of Medicine, University of Navarra, Pamplona, Spain
| | - M A Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitary Dexeus, Barcelona, Spain
| | - S Ajossa
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, University of Cagliari, Cagliari, Italy
| | - S Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, University of Cagliari, Cagliari, Italy
| | - J Vara
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
| | - M Linares
- Department of Obstetrics and Gynecology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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6
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Chen Y, Liu M, Zhang M, Yang M, Weng Z, Wu Q, He S. Ultrasonographic scoring system for the diagnosis of adnexal torsion. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:525-531. [PMID: 35244941 DOI: 10.1002/jcu.23178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To establish the utility of an ultrasonographic scoring system for the diagnosis of adnexal torsion. METHODS We retrospectively analyzing 358 adnexal torsion cases. Using Pearson's χ2 test we determined whether ultrasonographic signs were significantly associated with adnexal torsion. Receiver operating characteristic curves were used to evaluate the diagnostic efficacy of the system. Ultimately by using binary logistic regression we established a precise and convenient scoring system. RESULTS The torsion score was based on five criteria that were identified to be independently associated with adnexal torsion: (1) abnormal position of the index adnexa (odds ratio [OR], 2.311); (2) presence of a mass or cyst (OR, 3.495); (3) unilateral ovarian enlargement (OR, 3.051); (4) vascular pedicle twisting (OR, 2.105); and (5) peripheral hypervascularity of the corpus luteum with ovarian edema(encapsulating cyst sign) (OR, 4.164).patients with torsion who scored 0, have a predicted diagnosis rate of 20.9%; patients whose scores were 1,2 have a predicted probability of 41.8% and 66.15%, respectively. For patients with torsion scores of 3, 4, and 5, predicted diagnosis rates were 84.16%, 93.52%, and 98.27%, respectively. CONCLUSION The ultrasonographic scoring system is feasible and precisely diagnoses adnexal torsion using ultrasound.
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Affiliation(s)
- Yan Chen
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Min Liu
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Meilian Zhang
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Minmin Yang
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Zongjie Weng
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiumei Wu
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Suhui He
- Department of Ultrasound, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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7
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Miranian D, Schwartz A, Jiang C, Ndukwe JK, Caldwell M, Lim C, Marsh EE. Emergency Department Utilization for Adnexal Torsion: An Analysis of the Nationwide Emergency Department Sample from 2006-2018. J Minim Invasive Gynecol 2022; 29:1068-1074. [DOI: 10.1016/j.jmig.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/21/2022] [Accepted: 05/24/2022] [Indexed: 11/17/2022]
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8
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Bridwell RE, Koyfman A, Long B. High risk and low prevalence diseases: Ovarian torsion. Am J Emerg Med 2022; 56:145-150. [PMID: 35397355 DOI: 10.1016/j.ajem.2022.03.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Ovarian torsion is a rare, frequently misdiagnosed condition that carries with it a high rate of morbidity. OBJECTIVE This review highlights the pearls and pitfalls of ovarian torsion, including presentation, evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION Ovarian torsion is one of the most common gynecological surgical emergencies and occurs with complete or partial rotation of the ovary along the supporting ligaments, obstructing vascular flow. Several risk factors include the presence of an ovarian mass or cyst. The most common population affected includes reproductive aged women, though cases also occur in premenarchal females, pregnant women, and postmenopausal women. Abdominal or pelvic pain is common but is not always sudden in onset or severe. Nausea and vomiting occur in 70%. Ultrasound can assist with diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Computed tomography with intravenous contrast can assist with diagnosis. Treatment includes emergent gynecologic consultation for surgical detorsion, along with symptomatic therapy in the ED. CONCLUSIONS An understanding of ovarian torsion can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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9
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Silber M, Gilboa Y, Perlman S, Krispin E, Sukenik S, Shochat T, Hadar E, Bardin R. Accurate Diagnosis of Adnexal Torsion-Not Only for Expert Sonographers: A Retrospective Cohort Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:725-732. [PMID: 34013996 DOI: 10.1002/jum.15756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The aim of the study was to evaluate the clinical and sonographic parameters associated with a correct or incorrect diagnosis of adnexal torsion made by resident/attending physicians who are not expert sonographers. METHODS A retrospective study design included women who presented to the Emergency Department (ED) of a tertiary medical center between 2010 and 2019 with acute lower abdominal pain, who were subsequently diagnosed laparoscopically with adnexal torsion. Women who were correctly diagnosed in the ED by an obstetrician-gynecologist who was not an expert sonographer were compared for clinical and sonographic parameters with women who were initially incorrectly diagnosed and underwent a second ultrasound examination by an expert sonographer following admission. RESULTS Of 118 women with surgically proven adnexal torsion, 76 were correctly diagnosed in the ED and 42 were initially incorrectly diagnosed. The correctly diagnosed group was characterized by a significantly shorter mean time from admission to surgery, higher rate of vomiting, shorter duration of abdominal pain, and higher rate of prior torsion (P < .05). Physicians who made the correct diagnosis utilized more sonographic parameters than those who did not, namely ovarian size, ovarian edema, and Doppler flow. The correctly diagnosed group had a higher rate of bluish-black (ischemic) adnexa at laparoscopy, but a higher rate of recovery following detorsion. CONCLUSIONS Physicians in the ED should be alerted to the need to address some basic sonographic features when adnexal torsion is suspected. The diagnostic accuracy of adnexal torsion can be improved by utilizing simple sonographic markers, even in the ED setting.
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Affiliation(s)
- Michal Silber
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Yinon Gilboa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Sharon Perlman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Eyal Krispin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Shai Sukenik
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Tzippy Shochat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Statistical Consulting Unit, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Eran Hadar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
| | - Ron Bardin
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Helen Schneider Women's Hospital, Rabin Medical Center-Beilinson Hospital, Petach Tikva, Israel
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Yaakov O, Ashwal E, Gemer O, Peled Y, Kapustian V, Namazov A, Eitan R, Krissi H. Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome? Gynecol Obstet Invest 2022; 87:100-104. [PMID: 35139515 DOI: 10.1159/000522501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/16/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to investigate whether surgery for adnexal detorsion within 6 hours from admission to the hospital is associated with less adnexal ischemia. DESIGN Retrospective cohort study Participants/Materials, Setting, Methods: This retrospective study was conducted at two university-affiliated medical centers, assessed women aged 18 to 45 years with adnexal torsion who hospitalized within 12 hours from pain onset and underwent surgery for detorsion within 24 hours. The study group was divided into 2 groups: early, surgical intervention within less than 6 hours and late, surgical intervention between 6 to 24 hours. The primary outcome was the rate of macroscopic appearance of ischemic adnexa. RESULTS Two-hundred and twenty women fulfilled the inclusion criteria. In 101 women, the adnexa with the torsion appeared macroscopically ischemic. There was no difference in ischemic adnexa between the early and late intervention groups. (48% vs. 40%; P=0.269). No significant association was found between the physical examination or ultrasonographic findings and the rate of ischemic adnexa within each group. LIMITATIONS The main limitations of our study are its retrospective nature. Much of the clinical and ultrasonographic data are subjective and operator dependent. The decision to operate may vary from one surgeon to another. CONCLUSION Immediate surgical intervention in patients with adnexal torsion is not associated with a lower rate of adnexal ischemia. These findings suggest that in acute adnexal torsion there wider time window to for a thorough evaluation before surgery.
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Affiliation(s)
- Odelia Yaakov
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ashkelon, Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Ofer Gemer
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of Negev, Beer Sheva, Israel
| | - Yoav Peled
- Department of Obstetrics and Gynecology, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Victoria Kapustian
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of Negev, Beer Sheva, Israel
| | - Ahmet Namazov
- Department of Obstetrics and Gynecology, Barzilai University Medical Center, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of Negev, Beer Sheva, Israel
| | - Ram Eitan
- Department of Obstetrics and Gynecology, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
| | - Haim Krissi
- Department of Obstetrics and Gynecology, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petach Tikva, Israel
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11
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Petousis S, Chatzakis C, Westerway SC, Abramowicz JS, Dinas K, Dong Y, Dietrich CF, Sotiriadis A. World Federation for Ultrasound in Medicine Review Paper: Incidental Findings during Obstetrical Ultrasound. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:10-19. [PMID: 34702644 DOI: 10.1016/j.ultrasmedbio.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 06/13/2023]
Abstract
Although the prevalence of incidental findings revealed during an obstetric ultrasound examination is low, the findings may include adnexal and cervical masses, uterine or urinary congenital malformations, free fluid in the pouch of Douglas or tortuous vessels (varices). Adnexal masses are the most common finding and vary in imaging characteristics. They are mainly unilateral, cystic masses with a low risk of malignancy that are treated conservatively. The International Ovarian Tumor Analysis scoring models may be helpful in differentiating benign from malignant masses. For those masses >5 cm, follow-up is recommended, and resection could be considered to avoid risk of torsion, rupture and hemorrhage, which may compromise pregnancy outcome. Uterine masses such as fibroids are commonly diagnosed early in the first trimester and should be followed up during pregnancy to evaluate any changes. Transabdominal and transvaginal ultrasound is the first-line test for the diagnosis of such incidentalomas; however, magnetic resonance ultrasound may have a useful role in excluding malignancy potential. As a result of their low frequency and the lack of good evidence, there are no specific guidelines on the management of incidentalomas detected at obstetric scans. Their management should follow the related general guidelines for ovarian, cervical and uterine masses, with individualized management depending on the pregnancy status.
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Affiliation(s)
- Stamatios Petousis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Christos Chatzakis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | | | - Jacques S Abramowicz
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
| | - Konstantinos Dinas
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
| | - Yi Dong
- Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland.
| | - Alexandros Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Greece
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12
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Adu-Bredu TK, Arkorful J, Appiah-Denkyira K, Wiafe YA. Diagnostic value of the sonographic whirlpool sign in the diagnosis of ovarian torsion: A systematic review and meta-analysis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:746-753. [PMID: 34021602 DOI: 10.1002/jcu.23021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 06/12/2023]
Abstract
In this review, we investigated the diagnostic value of the sonographic "whirlpool sign" in identifying ovarian torsion. This was done by performing a search in PubMed, Scopus, Embase, Web of Science, CINAHL, and Google scholar. Additional search for the grey literature was made in EThOS.bl.uk, explore.bl.uk, opengrey.eu, greylit.org, and clinicaltrials.org. A total of eight studies were included in this meta-analysis. Sensitivity and specificity of whirlpool sign were extracted from the studies and computed into the Metadisc statistical software for pooled analysis. The whirlpool sign showed a high sensitivity and specificity for the diagnosis of ovarian torsion.
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Affiliation(s)
- Theophilus Kofi Adu-Bredu
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Medical Diagnostics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Joseph Arkorful
- Department of Medical Diagnostics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwame Appiah-Denkyira
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Yaw Amo Wiafe
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Medical Diagnostics, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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13
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Yatsenko O, Vlachou PA, Glanc P. Predictive Value of Single or Combined Ultrasound Signs in the Diagnosis of Ovarian Torsion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1163-1172. [PMID: 32941680 DOI: 10.1002/jum.15497] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 08/06/2020] [Accepted: 08/08/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To determine predictive values of isolated and combined ultrasound signs in the diagnosis of adnexal torsion. METHODS This work was a retrospective study of 129 adult female patients who underwent an ultrasound examination followed by a definitive surgical procedure within a 24-hour period to determine whether adnexal torsion was present. RESULTS The positive predictive value (PPV) of the ultrasound diagnosis of adnexal torsion was 82.2%. The statistically significant ultrasound signs in multivariate logistic regression with single-predictor analyses were relative enlargement of the ovary, an abnormal adnexal position, a twisted vascular pedicle, and the follicular edema "ring sign." Possible combinations of these ultrasound criteria showed high specificities (74%-100%), high PPVs (93%-100%), and lower sensitivities (29%-71%) and negative predictive values (24%-35%). Any combination that included a twisted vascular pedicle or the follicular ring sign as one of the signs had high odds ratios and positive likelihood ratios. CONCLUSIONS Ultrasound has a high PPV as a first-choice imaging modality in the diagnosis of adnexal torsion. The combinations of the following 4 statistically significant ultrasound signs, consisting of an abnormal position, relative enlargement of the index ovary, a twisted vascular pedicle, and the follicular edema ring sign, substantially narrow the imaging differential diagnosis in such cases. The presence of vascular pedicle twisting and the follicular ring sign was highly associated with a positive ovarian torsion diagnosis, with 100% specificity.
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Affiliation(s)
- Oleg Yatsenko
- Department of Radiology, Peterborough Regional Health Center, Peterborough, Ontario, Canada
| | - Paraskevi A Vlachou
- Department of Medical Imaging, St Michael's Hospital, Toronto, Ontario, Canada
| | - Phyllis Glanc
- University of Toronto, Toronto, Ontario, Canada
- Department of Medical Imaging, Body Division, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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Sugi MD, Patel AG, Yi J, Patel MD. The Flipped Ovary Sign in Ovarian Torsion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:839-843. [PMID: 32870519 DOI: 10.1002/jum.15462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/03/2020] [Accepted: 07/06/2020] [Indexed: 06/11/2023]
Abstract
The diagnosis of ovarian torsion is challenging and relies mostly on morphologic findings. Occasionally, women or children with acute pelvic pain who have undergone an initial ultrasound (US) evaluation with results interpreted as negative for ovarian torsion will return with recurrent or increasing pain, prompting an US reevaluation. The flipped ovary sign refers to a demonstrable change in the orientation of the ovary on follow-up US examinations, recognized by changing positions of ovarian landmarks established by follicles, cysts, or masses. This sign is valuable for identifying ovarian torsion in these patients, even in the absence of classic morphologic or Doppler features of ovarian torsion.
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Affiliation(s)
- Mark D Sugi
- Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound, University of California, San Francisco, California, USA
| | - Anika G Patel
- Department of Radiology, Division of Ultrasound, Mayo Clinic, Scottsdale, Arizona, USA
| | - Johnny Yi
- Department of Medical and Surgical Gynecology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Maitray D Patel
- Department of Radiology, Division of Ultrasound, Mayo Clinic, Scottsdale, Arizona, USA
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15
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Kitami M, Aoki H, Saito M. "Follow the Fallopian tube": A technique to improve sonographic identification of ovaries in children. JOURNAL OF CLINICAL ULTRASOUND : JCU 2021; 49:33-37. [PMID: 32827154 DOI: 10.1002/jcu.22906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/22/2020] [Accepted: 07/29/2020] [Indexed: 06/11/2023]
Abstract
Ovary detection is the first step in confirming ovarian lesions. The daughter cyst sign is widely used for this purpose; however, it is not always applicable. Recent improvements in image resolution allow Fallopian tube delineation, which can serve as a guide to identify the ovary. This anatomical approach ("follow the Fallopian tube" technique) comprises three steps: (1) confirm the uterus; (2) follow the Fallopian tube; and (3) find the ovary. Other applications of this approach include the differentiation between nonovarian and ovarian masses and ruling out ovarian torsion and an auto-amputated ovary.
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Affiliation(s)
- Masahiro Kitami
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hidekazu Aoki
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Mioko Saito
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
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16
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Bardin R, Perl N, Mashiach R, Ram E, Orbach-Zinger S, Shmueli A, Wiznitzer A, Hadar E. Prediction of Adnexal Torsion by Ultrasound in Women with Acute Abdominal Pain. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2020; 41:688-694. [PMID: 31703238 DOI: 10.1055/a-1014-2593] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. MATERIALS AND METHODS Retrospective cohort analysis of 322 women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. RESULTS The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). CONCLUSION Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.
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Affiliation(s)
- Ron Bardin
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Noga Perl
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Reuven Mashiach
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Ram
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | | | - Anat Shmueli
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Arnon Wiznitzer
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
| | - Eran Hadar
- Helen-Schneider-Hospital for Women, Rabin Medical Center, Petah Tikva, Israel
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17
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Moro F, Bolomini G, Sibal M, Vijayaraghavan SB, Venkatesh P, Nardelli F, Pasciuto T, Mascilini F, Pozzati F, Leone FPG, Josefsson H, Epstein E, Guerriero S, Scambia G, Valentin L, Testa AC. Imaging in gynecological disease (20): clinical and ultrasound characteristics of adnexal torsion. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:934-943. [PMID: 31975482 DOI: 10.1002/uog.21981] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 12/31/2019] [Accepted: 01/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To describe the clinical and ultrasound characteristics of adnexal torsion. METHODS This was a retrospective study. From the operative records of the eight participating gynecological ultrasound centers, we identified patients with a surgically confirmed diagnosis of adnexal torsion, defined as surgical evidence of ovarian pedicle, paraovarian cyst and/or Fallopian tube twisted on its own axis, who had undergone preoperative ultrasound examination by an experienced examiner, between 2008 and 2018. Only cases with at least two available ultrasound images and/or videoclips (one grayscale and one with Doppler evaluation) were included. Clinical, ultrasound, surgical and histological information was retrieved from each patient's medical record and entered into an Excel file by the principal investigator at each center. In addition, two authors reviewed all available ultrasound images and videoclips of the twisted adnexa, with regard to the presence of four predefined ultrasound features reported to be characteristic of adnexal torsion: (1) ovarian stromal edema with or without peripherally displaced antral follicles, (2) the follicular ring sign, (3) the whirlpool sign and (4) absence of vascularization in the twisted organ. RESULTS A total of 315 cases of adnexal torsion were identified. The median age of the patients was 30 (range, 1-88) years. Most patients were premenopausal (284/314; 90.4%) and presented with acute or subacute pelvic pain (305/315; 96.8%). The surgical approach was laparoscopic in 239/312 (76.6%) patients and conservative surgery (untwisting with or without excision of a lesion) was performed in 149/315 (47.3%) cases. According to the original ultrasound reports, the median largest diameter of the twisted organ was 83 (range, 30-349) mm. Free fluid in the pouch of Douglas was detected in 196/275 (71.3%) patients. Ovarian stromal edema with or without peripherally displaced antral follicles was reported in the original ultrasound report in 167/241 (69.3%) patients, the whirlpool sign in 178/226 (78.8%) patients, absent color Doppler signals in the twisted organ in 119/269 (44.2%) patients and the follicular ring sign in 51/134 (38.1%) patients. On retrospective review of images and videoclips, ovarian stromal edema with or without peripherally displaced antral follicles (201/254; 79.1%) and the whirlpool sign (139/153; 90.8%) were the most commonly detected features of adnexal torsion. CONCLUSION Most patients with surgically confirmed adnexal torsion are of reproductive age and present with acute or subacute pain. Common ultrasound signs are an enlarged adnexa, the whirlpool sign, ovarian stromal edema with or without peripherally displaced antral follicles and free fluid in the pelvis. The follicular ring sign and absence of Doppler signals in the twisted organ are slightly less common signs. Recognizing ultrasound signs of adnexal torsion is important so that the correct treatment, i.e. surgery without delay, can be offered. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Moro
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - G Bolomini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - M Sibal
- Department of Fetal Medicine and Obstetric and Gynecologic Ultrasound, Manipal Hospital, Bangalore, India
| | | | - P Venkatesh
- Department of Fetal Medicine and OBGYN Ultrasound, Manipal Hospital, Bangalore, India
| | - F Nardelli
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Institute for Women's Health, University College Hospital, London, UK
| | - T Pasciuto
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - F Mascilini
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
| | - F Pozzati
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - F P G Leone
- Department of Obstetrics and Gynecology, Biomedical and Clinical Sciences Institute L. Sacco, University of Milan, Milan, Italy
| | - H Josefsson
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
| | - E Epstein
- Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - G Scambia
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - A C Testa
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Rome, Italy
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, Rome, Italy
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18
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Sales A. Sonographic Diagnosis of a Mature Cystic Teratoma Resulting in Acute Torsion. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020. [DOI: 10.1177/8756479319895454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mature cystic teratomas are benign germ cell tumors and, depending on the size, may be at risk for torsion. These ovarian masses can cause the ovarian vasculature to twist upon itself and inhibit blood flow, resulting in partial to complete torsion. If detection and treatment are not prompt, a salpingo-oophorectomy may be needed impeding future fertility. This case describes a young woman with acute left adnexal pain where sonography aided in the diagnosis of ovarian torsion caused by a large mature cystic teratoma. Transabdominal sonography was used, aided by extended field-of-view technology for characterization of the mass. The sonographic attributes of mature cystic teratomas vary, but careful evaluations can lead to an accurate diagnosis to aid in surgical procedures. The patient underwent an exploratory laparotomy, which resulted in a left ovary oophorectomy and excision of the mass.
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Affiliation(s)
- Amber Sales
- University of Colorado Hospital, Aurora, CO, USA
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19
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Ovarian torsion: developing a machine-learned algorithm for diagnosis. Pediatr Radiol 2020; 50:706-714. [PMID: 31970456 DOI: 10.1007/s00247-019-04601-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/21/2019] [Accepted: 12/19/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ovarian torsion is a common concern in girls presenting to emergency care with pelvic or abdominal pain. The diagnosis is challenging to make accurately and quickly, relying on a combination of physical exam, history and radiologic evaluation. Failure to establish the diagnosis in a timely fashion can result in irreversible ovarian ischemia with implications for future fertility. Ultrasound is the mainstay of evaluation for ovarian torsion in the pediatric population. However, even with a high index of suspicion, imaging features are not pathognomonic. OBJECTIVE We sought to develop an algorithm to aid radiologists in diagnosing ovarian torsion using machine learning from sonographic features and to evaluate the frequency of each sonographic element. MATERIALS AND METHODS All pediatric patients treated for ovarian torsion at a quaternary pediatric hospital over an 11-year period were identified by both an internal radiology database and hospital-based International Statistical Classification of Diseases and Related Health Problems (ICD) code review. Inclusion criteria were surgical confirmation of ovarian torsion and available imaging. Patients were excluded if the diagnosis could not be confirmed, no imaging was available for review, the ovary was not identified by imaging, or torsion involved other adnexal structures but spared the ovary. Data collection included: patient age; laterality of torsion; bilateral ovarian volumes; torsed ovarian position, i.e. whether medialized with respect to the mid-uterine line; presence or absence of Doppler signal within the torsed ovary; visualization of peripheral follicles; and presence of a mass or cyst, and free peritoneal fluid. Subsequently, we evaluated a non-torsed control cohort from April 2015 to May 2016. This cohort consisted of sequential girls and young adults presenting to the emergency department with abdominopelvic symptoms concerning for ovarian torsion but who were ultimately diagnosed otherwise. These features were then fed into supervised machine learning systems to identify and develop viable decision algorithms. We divided data into training and validation sets and assessed algorithm performance using sub-sets of the validation set. RESULTS We identified 119 torsion-confirmed cases and 331 torsion-absent cases. Of the torsion-confirmed cases, significant imaging differences were evident for girls younger than 1 year; these girls were then excluded from analysis, and 99 pediatric patients older than 1 year were included in our study. Among these 99, all variables demonstrated statistically significant differences between the torsion-confirmed and torsion-absent groups with P-values <0.005. Using any single variable to identify torsion provided only modest detection performance, with areas under the curve (AUC) for medialization, peripheral follicles, and absence of Doppler flow of 0.76±0.16, 0.66±0.14 and 0.82±0.14, respectively. The best decision tree using a combination of variables yielded an AUC of 0.96±0.07 and required knowledge of the presence of intra-ovarian flow, peripheral follicles, the volume of both ovaries, and the presence of cysts or masses. CONCLUSION Based on the largest series of pediatric ovarian torsion in the literature to date, we quantified sonographic features and used machine learning to create an algorithm to identify the presence of ovarian torsion - an algorithm that performs better than simple approaches relying on single features. Although complex combinations using multiple-interaction models provide slightly better performance, a clinically pragmatic decision tree can be employed to detect torsion, providing sensitivity levels of 95±14% and specificity of 92±2%.
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20
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Feng JL, Zheng J, Lei T, Xu YJ, Pang H, Xie HN. Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings. Quant Imaging Med Surg 2020; 10:137-147. [PMID: 31956537 DOI: 10.21037/qims.2019.11.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Differences in the ultrasonographic features and histological diagnosis of ovarian torsion in pregnant and non-pregnant women have not been defined. A better characterization of these features may help improve the accuracy of preoperative diagnosis. The present study aimed to compare the clinical characteristics, sonographic findings, operative procedures, and histological spectrum of ovarian torsion in pregnant and non-pregnant women. Methods This was a retrospective investigation of female patients at reproductive age with ovarian torsion between January 2010 and May 2017. Each patient received a detailed preoperative ultrasound, and the diagnosis was confirmed by surgery. The clinical characteristics, ultrasonic features, operative procedures, and histological diagnosis of ovarian torsion were retrieved from medical records and were compared in non-pregnant and pregnant patients according to the method of conception. Results The overall preoperative ultrasonic detection rate of ovarian torsion was 0.84, which was significantly different between pregnant and non-pregnant women. The presence of ovarian edema and abnormal adnexal positions also differed between pregnant and non-pregnant women. The ultrasonic features were not significantly different between the two pregnant sub-groups. The most common histologic diagnoses in the pregnant group and the non-pregnant group were a normal ovary and teratoma, respectively. The incidence of ovarian neoplasm was significantly lower in pregnant women. There were significant differences in the surgical procedures between the groups based on neoplastic or non-neoplastic lesions. Conclusions Ovarian edema, absence/decreased blood flow in the ovary, and the whirlpool sign were reliable ultrasonic markers for ovarian torsion at reproductive ages. The preoperative ultrasonic detection rate of ovarian torsion was higher in pregnant women, and ovarian edema was more common. The clinical features of ovarian torsion in pregnant women were similar, independent of the method of conception. In women with ovarian torsion, the incidence of non-neoplastic lesions was more frequent in pregnant women, whereas neoplastic lesions were more common in non-pregnant women. Ultrasonography provides useful parameters for the preclinical diagnosis of ovarian torsion to improve patient management.
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Affiliation(s)
- Jie-Ling Feng
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Ju Zheng
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Ting Lei
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yong-Jian Xu
- Center for Information Technology & Statistics, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Hui Pang
- Department of Medical Records Management, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Hong-Ning Xie
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
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21
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Bromley B. Gynecologic Ultrasound Evaluation of the Nongravid Woman with Pelvic Pain. Obstet Gynecol Clin North Am 2019; 46:581-594. [PMID: 31677743 DOI: 10.1016/j.ogc.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Pelvic pain is a common condition. Many underlying gynecologic and nongynecologic conditions can contribute to this symptom. Pelvic ultrasound using comprehensive 2-dimensional interactive imaging techniques as well as color Doppler and 3-dimensional imaging optimizes the detection of inciting etiologies.
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Affiliation(s)
- Bryann Bromley
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Diagnostic Ultrasound Associates, One Brookline Place, Suite 506, Brookline, MA 02445, USA
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22
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Ozekinci M, Kucuksayan E, Erdogan G, Aslan M, Pestereli E, Canpolat M, Sircan-Kucuksayan A. Histopathological and biochemical assessment of a novel diagnostic method for ovarian torsion. Biotech Histochem 2019; 95:203-209. [DOI: 10.1080/10520295.2019.1663558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- M. Ozekinci
- Department of Obstetrics and Gynaecology, Akdeniz University, Antalya, Turkey
| | - E. Kucuksayan
- Department of Medical Biochemistry, Alanya Alaaddin Keykubat University, Antalya, Turkey
| | - G. Erdogan
- Department of Pathology, Akdeniz University, Antalya, Turkey
| | - M. Aslan
- Department of Medical Biochemistry, Akdeniz University, Antalya, Turkey
| | - E. Pestereli
- Department of Pathology, Akdeniz University, Antalya, Turkey
| | - M. Canpolat
- Department of Biophysics, Akdeniz University, Antalya, Turkey
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24
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Foster G, Keene J. Isolated fallopian tubal torsion: A challenging ultrasound diagnosis. SONOGRAPHY 2019. [DOI: 10.1002/sono.12172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Grant Foster
- Medical Imaging; The Women's Hospital; Melbourne Australia
- BMI; Barwon Health; Geelong Australia
| | - Jacqueline Keene
- Medical Imaging; The Women's Hospital; Melbourne Australia
- Specialist Imaging for Women; Melbourne Australia
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25
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Gu X, Yang M, Liu Y, Liu F, Liu D, Shi F. The ultrasonic whirlpool sign combined with plasma d-dimer level in adnexal torsion. Eur J Radiol 2018; 109:196-202. [DOI: 10.1016/j.ejrad.2018.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/09/2018] [Accepted: 08/26/2018] [Indexed: 10/28/2022]
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Durairaj A, Gandhiraman K. Complications and Management of Paraovarian Cyst: A Retrospective Analysis. J Obstet Gynaecol India 2018; 69:180-184. [PMID: 30956474 DOI: 10.1007/s13224-018-1152-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 06/19/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction Despite their relative frequency, paraovarian cyst received only scant attention. Clinician should be aware of the complications of paraovarian cyst. Objective To analyse the clinical profile, complications and management of paraovarian cyst. Materials and Methods Retrospective analysis of 51 patients with operative diagnosis of paraovarian cyst was carried out at our institution over a 5-year period. Results Majority (60.78%) of paraovarian cysts were found in the third and fourth decades, and the mean age of the patients was 31.8 years. 62.74% patients with paraovarian cyst presented with abdominal pain, and the rest were an incidental finding. Ultrasound made a correct diagnosis in 47.05% of patients. Mean size of paraovarian cyst was 7.51 cm. Complications of paraovarian cyst noted in our study are cyst enlargement (79.62%), adnexal torsion (18.51%), haemorrhage (7.4%), rupture (1.85%) and benign tumour (12.96%). 84.31% paraovarian cysts were managed by laparoscopy. Fertility-sparing surgery was done in 57.39% of paraovarian cysts. Conclusion Paraovarian cyst should be considered in the differential diagnosis of adnexal mass. The importance of differentiating it from ovarian cyst cannot be overemphasized. Laparoscopic approach and preferably a fertility-sparing surgery should be considered in the management of complications of paraovarian cyst.
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Affiliation(s)
- Anitha Durairaj
- Department of Obstetrics and Gynaecology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu 625014 India
| | - Kavitha Gandhiraman
- Department of Obstetrics and Gynaecology, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu 625014 India
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Jourjon R, Morel B, Irtan S, Audureau E, Coulomb-L'Herminé A, Larroquet M, Ducou le Pointe H, Blondiaux E. Analysis of Clinical and Ultrasound Determinants of Adnexal Torsion in Children and Adolescents. J Pediatr Adolesc Gynecol 2017; 30:582-590. [PMID: 28396218 DOI: 10.1016/j.jpag.2017.03.142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/08/2017] [Accepted: 03/28/2017] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE We aimed to assess the performance of transabdominal ultrasonography (US) for diagnosis of adnexal torsion (AT) in children and adolescents and evaluate its clinical and US determinants. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We retrospectively (2004-2014) studied data for children referred for acute or subacute pelvic pain who underwent US and included children 3 months to 18 years old who underwent surgical exploration and/or clinical and radiological follow-up for at least 3 months. The evaluation of US diagnostic performance was on the basis of the proposed diagnosis after US: AT or no AT with or without mass. Clinical and US predictors of AT were identified using regression analysis. RESULTS Among 65 girls included (mean age 11.75 ± 4.49 years), 33 (50.8%) had AT. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of US for AT were 90.9%, 68.7%, 75%, 88%, and 80%, respectively. Overall, 20 of 33 (60.6%) AT patients had a mass, including 33% with mature teratomas. Patients with AT versus no AT more frequently showed vomiting (64% vs 28%; P = .008), ovarian edematous stroma with a peripheral distribution of follicles (45.5% vs 9.4%; P = .002) and a mass of pluritissular aspect (40% vs 0%; P < .0001). The quantitative US predictors of AT were total area ratio (ovary and mass)/area of the contralateral ovary 4.9 or greater (P = .0002) and surface area 18.5 cm2 or greater (P = .0003). CONCLUSION US has high sensitivity but low specificity for the diagnosis of AT in children. The predictive criteria are vomiting, presence of a pluritissular mass, 4.9 area ratio or greater, or surface area 18.5 cm2 or greater.
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Affiliation(s)
- Rebecca Jourjon
- Department of Radiology, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Baptiste Morel
- Department of Radiology, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Sabine Irtan
- Department of Surgery, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Etienne Audureau
- Public Health Department, Hôpital Henri Mondor (AP-HP), Université Paris Est Créteil, Créteil, France
| | - Aurore Coulomb-L'Herminé
- Department of Pathology, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Michèle Larroquet
- Department of Surgery, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Hubert Ducou le Pointe
- Department of Radiology, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France
| | - Eléonore Blondiaux
- Department of Radiology, Hôpital Trousseau - Hôpitaux Universitaires de l'Est Parisien (AP-HP), Université Pierre et Marie Curie, Paris, France.
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Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X, De Laveaucoupet J. What every radiologist should know about adnexal torsion. Emerg Radiol 2017; 25:51-59. [PMID: 28884300 DOI: 10.1007/s10140-017-1549-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/28/2017] [Indexed: 12/29/2022]
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Feng JL, Lei T, Xie HN, Li LJ, Du L. Spectrums and Outcomes of Adnexal Torsion at Different Ages. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:1859-1866. [PMID: 28480536 DOI: 10.1002/jum.14225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/28/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To investigate the role of ultrasound in the preoperative diagnosis of adnexal torsion and describe its histological spectrum and outcomes at different ages. METHODS This study comprised a retrospective investigation of a data set that included 195 female patients with clinically suspected adnexal torsion between January 2010 and July 2015. Each patient received a detailed pelvic ultrasound examination by an experienced ultrasound examiner, and a definitive diagnosis was achieved via surgery. The accuracy of an ultrasonic diagnosis of adnexal torsion was assessed. The patients were divided into three groups: female children and adolescents, fertile women, and postmenopausal women. The size, type, histological spectrum, and outcome of adnexal torsion in the different groups were also described. RESULTS The sensitivity, specificity, and accuracy of ultrasound were 0.84, 0.77, and 0.81, respectively. There were significant differences in the presence of ultrasonic hallmarks among the true positive, false positive, and false negative cases of adnexal torsion. Ovarian torsion was identified in 94 cases, and isolated tubal torsion was identified in 15 cases. The most common histologic diagnoses of the pediatric group and the other two groups were a normal ovary and teratoma, respectively. The most common histologic diagnoses in the cases of isolated tubal torsion were mesosalpinx cyst and oviduct inflammation. CONCLUSIONS Ultrasonography plays an important role in the preoperative diagnosis of adnexal torsion. Despite ovarian involvement in most of the cases, isolated oviduct torsion was not uncommon. The spectrum of histological diagnoses varied among the age groups.
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Affiliation(s)
- Jie-Ling Feng
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ting Lei
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Hong-Ning Xie
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Li-Juan Li
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liu Du
- Department of Ultrasonic Medicine, Fetal Medical Center, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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Kitami M. Ultrasonography of pediatric urogenital emergencies: review of classic and new techniques. Ultrasonography 2017; 36:222-238. [PMID: 28494525 PMCID: PMC5494863 DOI: 10.14366/usg.17011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/18/2017] [Accepted: 03/30/2017] [Indexed: 12/28/2022] Open
Abstract
Urogenital emergencies are fairly common in the pediatric population, and a timely and correct diagnosis is necessary to avoid possible future infertility. In this field, ultrasonography is essential, as it has the advantages of being radiation-free and readily accessible. In particular, a high-frequency transducer allows precise evaluation of the morphology and vascularity of the scrotum, which is on the surface of the body. Beyond conventional techniques, new advanced imaging techniques have been developed, including elastography and contrast-enhanced ultrasonography. However, several pitfalls remain in the diagnosis of urogenital diseases using ultrasonography. Thus, accurate knowledge and sufficient experience with the technique are essential for making a correct diagnosis. This review provides an overview of pediatric urogenital emergency pathologies and recent ultrasonography techniques.
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Affiliation(s)
- Masahiro Kitami
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Abstract
Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%-15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.
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Affiliation(s)
- Ci Huang
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan
| | - Mun-Kun Hong
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Dah-Ching Ding
- Department of Obstetrics and Gynecology, Buddhist Tzu Chi General Hospital and Tzu Chi University, Hualien, Taiwan.,Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
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Abstract
Imaging is crucial in expediting the diagnosis and guiding definitive therapy in children with ovarian torsion. This article reviews the multimodality spectrum of imaging findings in pediatric ovarian torsion, focusing primarily on US appearances. We describe predisposing conditions that can lead to torsion, the pathological basis of the radiologic findings in ovarian torsion, and the common diagnostic pitfalls.
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Affiliation(s)
- Anh-Vu Ngo
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA
| | - Jeffrey P Otjen
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA
| | - Marguerite T Parisi
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA
| | - Mark R Ferguson
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA
| | - Randolph K Otto
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA
| | - A Luana Stanescu
- Department of Radiology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way N.E., Seattle, WA, 98105, USA.
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Yaakov O, Zohav E, Kapustian V, Gdalevich M, Volodarsky M, Anteby EY, Gemer O. Are Ultrasonographic Findings Suggestive of Ovarian Stromal Edema Associated with Ischemic Adnexal Torsion? Gynecol Obstet Invest 2015; 81:262-6. [PMID: 26336916 DOI: 10.1159/000437422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 07/05/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study whether sonographic findings suggestive of ovarian stromal edema are associated with tissue ischemia in patients with adnexal torsion. METHODS A study of 79 patients with adnexal torsion was performed. Patients were divided into an ischemic group, in which the twisted adnexa were seen as blue or black, and a non-ischemic group, in which the adnexa retained normal color and appeared viable. Clinical and ultrasonographic findings, specifically the presence of ultrasonographic signs suggestive of ovarian stromal edema, were compared between the two groups. RESULTS Of the 79 patients with torsion, in 44 (55.7%) the adnexa appeared ischemic at surgery. The presence of ischemia was not associated with age, pregnancy, duration of pain, vomiting or findings at physical examination. There was no significant difference between the ischemic and the non-ischemic group in the proportion of patients with signs of ovarian stromal edema (59 vs. 40%, p = 0.11), in the proportion of patients with absent/diminished stromal Doppler flow (36 vs. 28%, p = 0.12%) or in the proportion of patients with both signs of stroma edema and absent/diminished stromal Doppler flow (20 vs. 12%, p = 0.36). CONCLUSION Ultrasonographic signs of ovarian stromal edema do not assist in differentiating between ischemic and non-ischemic adnexal torsion.
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Affiliation(s)
- Odelia Yaakov
- Department of Obstetrics and Gynecology and Epidemiology Institute 1, Ben-Gurion University, Barzilai Medical Center, Ashkelon, Israel
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Nair S, Joy S, Nayar J. Five year retrospective case series of adnexal torsion. J Clin Diagn Res 2014; 8:OC09-13. [PMID: 25653994 DOI: 10.7860/jcdr/2014/9464.5251] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 10/30/2014] [Indexed: 11/24/2022]
Abstract
AIMS AND OBJECTIVES Adnexal torsion is a rare gynaecological emergency that requires an early surgical intervention to save the adnexa from irreversible damage .Our study is about clinical presentation and management approach of adnexal torsion in a tertiary care centre. STUDY DESIGN Retrospective study. MATERIALS AND METHODS Review of case records during the five years of 2008 November -2013 November in Amrita Institute of Medical Sciences, Kochi, India. RESULTS Adnexal torsion was found mainly in the reproductive age. Ultrasound was the most commonly used imaging modality. Benign tumours predispose to torsion. Torsion occurred during postovulatory period in many cases. Polycystic ovaries were a risk factor for unexplained torsion in younger age groups. Diagnosis of adnexal torsion was mostly intra operative by direct visualisation of the rotated adnexa. Laparoscopy was the preferred method of surgical intervention. Ovarian conservation was tried in majority of the child bearing age groups. CONCLUSION Adnexal torsion is a rare emergency which requires a high index of clinical suspicion for diagnosis as the symptoms are non specific. Imaging helps in diagnosis but most of them are diagnosed intra operatively. Laparoscopic conservative surgery is the preferred surgical approach especially in younger age groups. An early surgical intervention helps in salvaging the adnexa and prevents further complications.
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Affiliation(s)
- Sobha Nair
- Assistant Professor, Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences , Kochi, Kerala, India
| | - Smitha Joy
- Assistant Professor, Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences , Kochi, Kerala, India
| | - Jayashree Nayar
- Professor, Department of Obstetrics and Gynaecology, Amrita Institute of Medical Sciences , Kochi, Kerala, India
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Knez J, Day A, Jurkovic D. Ultrasound imaging in the management of bleeding and pain in early pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:621-36. [PMID: 24841987 DOI: 10.1016/j.bpobgyn.2014.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/16/2014] [Accepted: 04/10/2014] [Indexed: 12/27/2022]
Abstract
Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.
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Affiliation(s)
- Jure Knez
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Andrea Day
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK.
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Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy. J Ultrasound 2014; 17:41-6. [PMID: 24616750 DOI: 10.1007/s40477-013-0059-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 12/05/2013] [Indexed: 10/25/2022] Open
Abstract
Several surgical and/or medical emergencies/urgencies may occur in gynecologic patients and in pregnant women during the first trimester. Particularly, ectopic pregnancies, ruptured or hemorrhagic ovarian cysts, ovarian or adnexal torsions, threatened or inevitable miscarriages, phlogistic gynecological disorders, complications involving the uterine fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications. The diagnosis is suspected on the basis of symptoms (acute pelvic and/or abdominal pain, with or without vaginal bleeding or discharge, until acute abdomen with peritonitis), by means physical evaluation (abdominal, pelvic, and bimanual gynecological examinations), by means of transabdominal (TAS) and/or transvaginal (TVS) sonography, and laboratory tests. However, the diagnosis is often not that simple, especially when the symptoms and clinical signs are minimal, and ultrasound (US) examination is not diriment. The differential diagnosis of abdominal/pelvic pain is broad and includes primarily gastrointestinal and urogenital disorders. Generally, TAS should usually be used in conjunction with TVS for evaluation of the female pelvis. If the US examination is not conclusive, CT or MRI, especially in pregnant patients, should be considered.
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Deffieux X, Thubert T, Huchon C, Demoulin G, Rivain AL, Faivre E, Trichot C. [Complications of presumed benign ovarian tumors]. ACTA ACUST UNITED AC 2013; 42:816-32. [PMID: 24210240 DOI: 10.1016/j.jgyn.2013.09.036] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The main risk factor of adnexal torsion is a previous adnexal torsion (LE3). There is no clinical, biological or radiological sign that may exclude the diagnosis of adnexal torsion (LE3). The presence of flow at color Doppler imaging does not allow exclusion of the diagnosis (LE2). An emergent laparoscopy is recommended for adnexal untwisting (Grade B), except in postmenopausal women where oophorectomy is recommended (grade C). A persistent black color of the adnexa after untwisting is not an indication for systematic oophorectomy (grade C), since a functional recovery is possible (LE3). Ovariopexy is not routinely recommended following adnexal untwisting (grade C). The clinical signs of intra-cystic hemorrhage and those of rupture of the corpus luteum are not specific (LE4). MRI is not recommended to confirm the diagnosis of intra-cystic hemorrhage (grade C). Malignant transformation of an ovarian cyst is very rare. The presence of a benign ovarian cyst is not associated with an increased risk of ovarian cancer at long-term follow-up (LE2). For these women, an ultrasound follow-up is not recommended (grade C). Dermoid ovarian cyst containing nerve tissue can trigger the production of pathogenic auto-antibody-anti-NMDA, leading to encephalitis. A high proportion of thyroid tissue in a mature teratoma (struma ovarii) may cause hyperthyroidism.
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Affiliation(s)
- X Deffieux
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France; Faculté de médecine, université Paris-Sud, 91405 Orsay, France.
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Navve D, Hershkovitz R, Zetounie E, Klein Z, Tepper R. Medial or lateral location of the whirlpool sign in adnexal torsion: clinical importance. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1631-1634. [PMID: 23980225 DOI: 10.7863/ultra.32.9.1631] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES The whirlpool sign is used as a sonographic marker for adnexal torsion. The aims of this study were to describe the location of the whirlpool sign (lateral or medial to the ovary) and to evaluate the clinical importance of the location. METHODS Thirty patients with a confirmed surgical diagnosis of torsion and a positive whirlpool sign on sonography before surgery were included. We examined the sonographic clips of these patients. Classic signs of adnexal torsion were determined: ovarian edema, the presence of a mass, pelvic free fluid, and ovarian ischemia on Doppler imaging. The whirlpool sign was detected on grayscale and color Doppler sonography by moving the transducer to and fro along the axis of suspected torsion. RESULTS Sixteen of 30 patients had right-sided torsion. Of these, 7 had a lateral whirlpool sign. All 7 of these patients had an ovarian or paraovarian mass. Nine of these 16 patients had a medial whirlpool sign. Of these, 7 had an ovarian or paraovarian mass, and 2 had no mass. Of the 14 patients with left-sided torsion, all had a medial whirlpool sign. Nine of 14 these patients had an ovarian or paraovarian mass, and 5 had no mass. The mean volume of the masses among cases with the lateral whirlpool sign was significantly greater compared to those with the medial whirlpool sign (304 versus 108 cm(3); P = .035). In 25 of 30 cases, the torsed components included the ovary. CONCLUSIONS The lateral whirlpool sign is associated with enlarged masses in comparison to the medial whirlpool sign. This finding indicates the need to search meticulously for the lateral whirlpool sign in cases with enlarged masses to decide whether to operate on these patients emergently.
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Sibal M. Follicular ring sign: a simple sonographic sign for early diagnosis of ovarian torsion. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:1803-1809. [PMID: 23091252 DOI: 10.7863/jum.2012.31.11.1803] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The follicular ring sign is a novel, easily identifiable sonographic finding of ovarian torsion consisting of hyperechoic rings around the antral follicles. In a retrospective analysis of 15 consecutive patients with torsion undergoing surgery, the follicular ring sign was frequently present, starting early in the disease course. This sign could be valuable for accurate and early diagnosis of torsion in the absence of specific conventional sonographic features.
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Affiliation(s)
- Mala Sibal
- Department of Fetal Medicine and Obstetric and Gynecologic Ultrasound, Manipal Hospital, Bangalore, India.
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Feng L, Liu Y, Liu H, Chen X. Chronic isolated fallopian tube torsion associated with huge hydrosalpinx and hemosalpinx in a postmenopausal woman: a case report and brief review. Eur J Obstet Gynecol Reprod Biol 2012; 164:235-6. [PMID: 22749784 DOI: 10.1016/j.ejogrb.2012.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 05/07/2012] [Accepted: 06/08/2012] [Indexed: 11/29/2022]
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Affiliation(s)
- Casey A Boyd
- University of Texas Medical Branch, Galveston, Texas, USA
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Schmitz G, Tibbles C. Genitourinary emergencies in the nonpregnant woman. Emerg Med Clin North Am 2011; 29:621-35. [PMID: 21782078 DOI: 10.1016/j.emc.2011.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Lower abdominal and pelvic pains are common symptoms in women who present to the emergency department (ED). Once pregnancy has been ruled out, attention should focus on other potential life or fertility threats. Ultrasound remains the most helpful initial diagnostic modality. Time-sensitive and serious conditions, such as large ovarian masses or abnormal vaginal bleeding, need gynecologic consultation. Because many patients do not have access to primary care, ED physicians should be familiar with the treatment of sexually transmitted diseases. However, most nonpregnant women with pelvic complaints can safely be managed in the outpatient setting after ED evaluation.
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Affiliation(s)
- Gillian Schmitz
- Department of Emergency Medicine, Georgetown University, Washington Hospital Center, Washington, DC 20010, USA.
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