Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Clinical features of isolated Fallopian tube torsion: evidence from a large series

We aimed at studying isolated Fallopian tube torsion (IFTT) in a relatively large cohort of women and to evaluate different features of IFTT in comparison to a large cohort of women with non-IFTT adnexal torsion (NIAT). This was a retrospective cohort study. We included women with surgically confirmed ovarian and/or Fallopian tube torsion between March 2011 and June 2020. Fifty-four cases of IFTT were surgically confirmed during the study period and were compared to 422 surgically confirmed NIAT. The rate of controlled ovarian hyperstimulation treatments, current pregnancy, and vomiting was lower in the IFTT group compared with the NIAT group. Cervical tenderness and vaginal discharge were more common in the IFTT group. Oedematous and enlarged ovaries were less common in the IFTT group. In multivariate regression analysis, the following factors were independently associated with IFTT: (i) vaginal discharge [adjusted odds ratio (aOR) 95% CI 8.16, 1.98-33.55]; (ii) cervical motion tenderness (aOR 95% CI 2.71, 1.01-7.29); (iii) fertility treatments (aOR 95% CI 0.26, 0.70-0.77); (iv) previous abdominal surgery (aOR 95% CI 0.46, 0.22-0.96); (v) vomiting (aOR 95% CI 0.38, 0.19-0.76); and (vi) enlarged ovary (aOR 95% CI 0.34, 0.18-0.65). In conclusion, we have identified factors positively and negatively associated with IFTT in a large cohort of women with adnexal torsion.

Inguinal hernia leading to omental torsion: Role of CT in differentiating from other clinical mimics - a case report and literature review

Omental torsion is a very rare cause of acute abdomen. Clinically, it mimics other common pathologies such as acute appendicitis, acute diverticulitis and acute cholecystitis. It is therefore no surprise, that it was rarely diagnosed pre operatively before the advent and easy availability of modern imaging techniques. CT scan, in particular, can diagnose omental torsion with confidence pre operatively. This can make conservative treatment possible in cases of primary omental torsion and guide regarding the appropriate treatment in cases of secondary torsion. We present a case of a young male patient who presented to Emergency department with symptoms of acute abdomen. Clinical and laboratory findings were non-specific for any specific cause of acute abdomen. CT scan, however, showed omental fat stranding with whirlpool sign representing omental torsion which was seen to be secondary to left inguinal hernia. Patient was operated in emergency and necrotic omentum was resected and hernia repaired. Post-operative recovery was uneventful.

Synchronous bilateral ovarian torsion followed by recurrent unilateral torsion in a patient undergoing fertility treatment: A case report and literature review

BACKGROUND

Ovarian torsion (OT) is a gynaecological emergency and requires prompt recognition and treatment in order to prevent the loss of ovarian function. Patients who are undergoing fertility treatment are at an increased risk of developing OT.

OBJECTIVE

The diagnosis of OT in patients undergoing fertility treatment can be challenging as they often present with abdominal pain and other non-specific symptoms. We highlight the importance of early diagnosis of suspected torsion and performed a literature review on cases of bilateral OT to review its presentation, investigation, and subsequent management.

CASE REPORT

A 32-year-old nulliparous woman who was undergoing controlled ovarian stimulation presented with lower abdominal pain and was initially managed as ovarian hyperstimulation syndrome (OHSS). Her pain did not subside following conservative management and she proceeded to have a laparoscopy which demonstrated synchronous bilateral ovarian torsion (SBOT), both ovaries were detorted. Eight months later, she was preparing for her frozen embryo transfer (FET) cycle, patient again presented with significant right sided abdominal pain and was found to have a recurrent torsion of the right ovary which was again detorted successfully.

CONCLUSIONS

Clinicians should have a low-threshold to investigate and rule out OT in patients who present with lower abdominal pain, especially in those with additional risk factors for torsion. Patients with confirmed torsion can be successfully managed with detorsion of the ovaries. Further research is needed to determine the best management option for patients with recurrent torsion episodes.

Adnexal torsion in childhood and adolescence

The incidence of adnexal torsion in childhood and adolescence is 4.9 per 100,000 girls. Torsion of the adnexa is caused by rotation of the ovary usually with the fallopian tube around the infundibulopelvic ligament. The torsion leads primarily to the interruption of both venous outflow and lymphatic drainage. It causes enlargement of the ovary due its edema with occurrence of hemorrhagic infarctions. Interruption of the arterial inflow leads finally to the necrosis of ovarian tissue. Torsion of the adnexa in childhood occurs usually in enlarged ovary, particularly by a cyst, or when the non-enlarged ovary is excessively mobile due to the extended infundibulopelvic ligament. The characteristic clinical symptoms of adnexal torsion are sudden pain in the lower abdomen with nausea and vomiting. The dia-gnosis of adnexal torsion is based on the typical symptoms, clinical course, and the results of physical and ultrasound examinations. Torsion of the adnexa should be considered in every girl with sudden abdominal pain. To preserve reproductive functions, an early surgery with detorsion of the adnexa should be performed.

Splenectomy for Torsion of a Wandering Spleen in a Patient with Myeloproliferative Disease

We herein report a rare case of torsion of a wandering spleen in a patient with myeloproliferative disease. A 66-year-old Japanese woman presented to our hospital with abdominal pain and a fever. She had a medical history of polycythemia and secondary myelofibrosis. Abdominal enhanced computed tomography showed an enlarged spleen without enhancement in the lower pelvic region. The clinical diagnosis was severe torsion of a wandering spleen in a patient with myeloproliferative disease, necessitating surgical intervention. Splenectomy was performed after de-rotating to revascularize the spleen. After the operation, the platelet count gradually increased, and aspirin was administered to prevent thrombosis.

Ultrasonographic scoring system for the diagnosis of adnexal torsion

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.

Acute abdomen caused by torsion of the omentum: A pediatric case report

RATIONALE

Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations.

PATIENT CONCERNS

A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis.

DIAGNOSIS

The patient was diagnosed with omental torsion based on imaging and laparoscopy.

INTERVENTIONS

Laparoscopic exploration was performed.

OUTCOMES

The patient was discharged seven days after satisfactory postoperative recovery.

LESSONS

Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis.

Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome?

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.

Omental torsion as a rare cause of pain in the right subcostal space - a case report

Omental torsion is a rare cause of abdominal emergency. Due to its clinical presentation and according to its localisation it is seldom diagnosed preoperatively as it imitates other more common diagnoses leading to surgical revision quite precisely. In this case report the authors present omental torsion with partial omental necrotisation in the right upper quadrant, imitating acute cholecystitis. The condition was managed by laparoscopic resection with a good clinical course postoperatively.

An Insidious Cause of Abdominal Pain in a Preschooler Girl: The Asynchronous Bilateral Ovarian Torsion

ABSTRACT

The ovarian torsion (OT) represents one of the most misleading and challenging diagnoses for the pediatrician. Symptoms are often nonspecific, including sudden, piercing localized lower abdominal pain and tenderness associated with a palpable mass and peritoneal signs. Although the adnexal torsion is most frequently unilateral, cases of bilateral synchronous or asynchronous have been recorded; in the latter, the OT involved both ovaries at different settings. We reported the case of a 6-year-old girl who presented an asynchronous bilateral OT.

Isolated torsion of a fallopian tube: an uncommon cause of abdominal pain in an 11-year-old

This report describes a rare case of isolated fallopian tube torsion (IFTT) in a premenarchal 11-year-old girl. The patient presented with subacute abdominal pain, associated with nausea and vomiting. Sonographic findings revealed left tube enlargement with free intraperitoneal fluid. Doppler mapping was not unequivocal. During exploratory laparoscopy, a large pelvic necrotic mass was found to be a twisted left fallopian tube. After detorsion, salpingectomy was performed and the patient recovered promptly, showing no complications 3 months post operation. IFTT should be considered as a differential diagnosis of lower abdominal pain in adolescent girls with normal-appearing ovaries on ultrasound. Conservative management for fertility preservation is the ideal approach. Therefore, avoiding delay in laparoscopy is crucial.

[Acute abdomen based on a wandering spleen]

BACKGROUND

A wandering spleen is a relatively unknown condition, where the spleen may be enlarged and is located in an aberrant position in the abdomen. It is caused by abnormally constructed or absent ligaments that should keep the spleen in the correct position or an excessively long vascular stem. The pathophysiology is congenital or secondary to trauma, abdominal surgery, pregnancy or splenomegaly.

CASE DESCRIPTION

A 21-year-old woman was presented at the emergency department with acute abdominal pain in the left lower quadrant. A CT-scan of the abdomen showed splenomegaly, with the spleen showing reduced blood flow and a location in the lower abdomen. During an emergency laparoscopy, the spleen was found to be ischemic based on a torsion of the vascular pedicle. A splenectomy followed and the patient showed an uncomplicated recovery.

CONCLUSION

Splenopexy or splenectomy is the treatment of choice for a symptomatic wandering spleen.

Challenge of diagnosing splenic torsion in a paediatric patient with gastroschisis

Gastroschisis is an uncommon congenital defect of the abdominal wall resulting in intestinal prolapse, most commonly associated with short gut syndrome or bowel obstruction. Wandering spleen, movement of the spleen due to the underdevelopment of splenic ligaments, has a prevalence of 0.25% and is asymptomatic in 15% of paediatric cases. An 11-year-old patient, admitted with a history of gastroschisis repaired at birth, presents with 18 months of intermittent, worsening abdominal pain. Imaging demonstrated splenomegaly and tortuosity of the splenic vein with abnormal positioning of the superior mesenteric artery and vein. The patient was found to have a wandering spleen with subacute splenic infarct secondary to splenic torsion, necessitating emergent surgical intervention. This patient experienced an extremely rare complication of gastroschisis that has not previously been reported. This complication is caused by a lack of appropriate abdominal fixation points for the spleen.

A Patient with Lung Adenocarcinoma Accompanied by Whole Right Lung Torsion Induced by the Accumulation of a Large Amount of Pleural Effusion

A 68-year-old man visited a physician with a chief complaint of difficulty breathing. Right pleural effusion was noted, and he was referred to our department for a close examination and treatment. Thoracoscopy was performed under local anesthesia, and pleural dissemination of lung adenocarcinoma was noted, so a chest drain was placed. Since poor right lung inflation persisted and whole right lung torsion was observed on computed tomography, thoracoscopy-assisted thoracotomic reduction of lung torsion was performed. In this patient, the right middle lobe and anterior chest wall were adhered, suggesting that whole right lung torsion occurred when atelectasis was formed due to pleural effusion.

Internal tibial torsion is related to syndesmosis injury in a large osteological collection

BACKGROUND

The long-term consequences of tibial torsion remain unclear. This study evaluated whether syndesmotic injuries are associated with tibial torsion.

METHODS

A collection of over 3000 cadaveric skeletons was screened for irregular bony prominence along the lateral distal tibia, consistent with previous syndesmosis injury. Tibial torsion was measured and compared to 1034 control cadaveric tibiae.

RESULTS

Mean torsion of 236 specimens with syndesmotic injury was 6.2±8.9 degrees, while that of control specimens was 7.9±8.8 degrees (P = 0.008). Multiple regression analysis showed a non-statistically significant trend toward internal torsion and syndesmotic injury (standardized beta=-0.051, P=0.059). Syndesmosis injury was present in 48/200 specimens (24.0%) with internal torsion and 31/199 specimens (15.6%) with external torsion (P=0.035).

CONCLUSION

This association between internal tibial torsion and syndesmotic injury suggests that internal tibial torsion might not be an entirely benign condition and merits further study.

Torsion of Wandering Spleen and its adherence to the right ovary - An unusual cause of recurrent pain abdomen

Wandering spleen is a rare condition in which the spleen is hypermobile due to laxity or lack of its supporting ligaments. It can be located anywhere in the abdomen besides its usual position. The other terms that are used to describe this condition are splenic ptosis, displaced spleen, dislocated spleen and ectopic spleen. Splenic torsion is a dreaded complication and the usual cause of symptoms. There is a high chance of missing the diagnosis as it remains asymptomatic or may be incidentally discovered on radio-imaging done for a different purpose. An acute abdomen is the most common presentation. Here we describe an unusual case presenting with torsion of the wandering spleen that was adherent to the right ovary.

Extralobar pulmonary sequestration with a complication of torsion: A case report and literature review

RATIONALE

Pulmonary sequestration is a congenital abnormality of the lower airway. It is characterized by a nonfunctioning mass of lung tissue that lacks normal communication with the tracheobronchial tree or pulmonary arteries and always receives its arterial blood supply from the systemic circulation. Most cases of extralobar pulmonary sequestrations (ELSs) are asymptomatic and found incidentally or in prenatal ultrasound screening.

PATIENT CONCERNS

A 10-year-old boy had severe chest pain and vomiting for 2 days.

DIAGNOSES

ELS was diagnosed, and torsion of the ELS had developed as a complication.

INTERVENTIONS

In video-assisted thoracoscopic surgery, the ELS was resected.

OUTCOMES

The clinical symptoms were relieved the 2nd day after surgery and did not recur over a follow-up period of 3 months.

LESSONS

In young patients with sudden abdominal pain or chest pain, in whom computed tomography shows a well-defined mass of homogeneous soft-tissue density in the thorax, ELS with torsion should be suspected. The presence of a feeding artery greatly supports the diagnosis of ELS, and the absence of this classic finding may indicate torsion of the pulmonary sequestration.

The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy

OBJECTIVES

Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication and the results are not widely published.

DESIGN AND SETTING

A single-center retrospective observational study.

POPULATION

34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as an additional modality when clinical, laboratory and ultrasound (USS) findings were indeterminate.

METHODS

Case notes were reviewed where pregnant women underwent a MRI investigation for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were excluded.

MAIN OUTCOME MEASURES

The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis.

RESULTS

The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case.

CONCLUSION

The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI should be considered in cases of abdomino-pelvic pain in pregnant women.

Comparison of Emergent and Elective Surgeries of Endometriomas: Is Adnexal Torsion a Concern?

BACKGROUND

When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected.

OBJECTIVES

To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries.

METHODS

This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion.

RESULTS

Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19).

CONCLUSIONS

Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.

Torsion of a uterine leiomyoma - a rare cause of hemoperitoneum; a case report and review of the literature

Uterine leiomyomas are common benign uterine tumors but by contrast, their acute complications are very rare. We present an unusual case of 38-year-old woman that came to the emergency department with acute abdominal pain. The ultrasound revealed hemoperitoneum, a uterus with two intramural fibroids and a tender inhomogeneous pelvic mass that seems to connect with the uterus. Computer tomographic (CT) examination raised the suspicion of a degenerated fibroid and hemoperitoneum. Emergency laparotomy was performed: the hemoperitoneum was determined by a degenerated fundal subserosalfibroid. Myomectomy was subsequently carried out. Even though this condition is extremely rare, every clinician has to bear in mind that acute fibroid complications can be a potential cause of acute abdominal pain that requires immediate surgery. The imagistic tools, ultrasound and CT are extremely helpful for the diagnosis.Due to its relative rarity in the second part of the article we have performed a review of the existing literature regarding the acute complications of fibroid torsion.

[A young woman with acute pain in the lower right abdomen]

A 19-year old woman with acute pain in the lower right quadrant of the abdomen was seen in the emergency room. Because we suspected an anomaly of the appendix, we performed a laparoscopy. We unexpectedly found a torsion of a Hydatid of Morgagni, a stalked cyst of the fallopian tube.

[A pregnant woman with acute abdominal pain]

A 23-year-old pregnant woman presented with acute right-sided abdominal pain and vomiting in the 21st week of gestation. An MRI scan showed an ovarian torsion and a dermoid cyst. On the same day, laproscopy was performed. After removal of the cyst, the pregnancy and the childbirth progressed without complications.

Axial Torsion and Infarction of Meckel\'s Diverticulum in the 3rd Trimester of Pregnancy

Meckel's diverticulum is a congenital anomaly which can become complicated or remain asymptomatic throughout life. During pregnancy, however, diverticulum infection could become a serious complication. Diverticulum necrosis and perforation are complications that increase morbidity in pregnancy, both maternal and fetal. The rarity of the condition and the maternal physiological changes in pregnancy make the diagnosis difficult. We present the case of a Meckel's diverticulum gangrene in third trimester pregnancy, atypical case due to advanced pregnancy where the risk-benefit balance was carefully evaluated on one hand because of the risk of infection associated with expectant management and on the other hand the risk and complications of iatrogenic preterm premature birth. The outcome was favorable for both mother and newborn.

[Isolated fallopian tubal torsion; rare or overlooked?]

Isolated fallopian tubal torsion (IFTT) is a rare cause of lower abdominal pain. It's difficult to diagnose preoperatively due to non-specific clinical symptoms. Furthermore, IFTT is often not considered in the differential diagnosis. Prompt diagnosis is critical, to prevent progression of symptoms and to maintain fertility; therefore, this article discusses diagnostic pitfalls and reports on key imaging features of IFTT that may facilitate preoperative diagnosis. IFTT should be suspected in a female patient with acute lower abdominal pain and a unilateral pelvic mass close to a normal ipsilateral ovary; there may be a history of prior tubal ligation. Specific imaging findings include the sonographic 'whirlpool sign' and absent flow during colour Doppler ultrasound. CT is often performed when the diagnosis remains unclear, but has no clinical consequences. IFTT requires emergency surgical treatment; detorsion without resection can be considered in women who would like to retain potential future fertility, but salpingectomy is often inevitable due to necrosis.

Pisa syndrome in Parkinson's disease: electromyographic quantification of paraspinal and non-paraspinal muscle activity

Patients with Parkinson's disease (PD) and Pisa syndrome (PS) may present tonic dystonic or compensatory (i.e. acting against gravity) hyperactivity in the paraspinal and non-paraspinal muscles. Electromyographic (EMG) activity was measured in nine patients with PD and PS, three with PD without PS, and five healthy controls. Fine-wire intramuscular electrodes were inserted bilaterally into the iliocostalis lumborum (ICL), iliocostalis thoracis (ICT), gluteus medius (GM), and external oblique (EO) muscles. The root mean square (RMS) of the EMG signal was calculated and normalized for each muscle. In stance condition, side-to-side muscle activity comparisons showed a higher RMS only for the contralateral ICL in PD patients with PS (p=0.028). Moreover, with increasing degrees of lateral flexion, the activity of the EO and the ICL muscles progressively increased and decreased, respectively. The present data suggest that contralateral paraspinal muscle activity plays a crucial compensatory role and can be dysfunctional in PD patients with PS.

Colonic obstruction caused by accessory spleen torsion: A rare case report and literature review

RATIONALE

Accessory spleen torsion is a rare cause of the acute abdomen. The complications of accessory spleen torsion, such as intestinal obstruction, are rarer. We herein report a case of colonic obstruction caused by accessory spleen torsion because of the unusual condition.

PATIENT CONCERNS

A 15-year-old patient presented with acute intestinal obstruction with signs of peritoneal irritation. Abdominal computed tomography (CT) and ultrasonography examinations revealed a soft tissue mass in the left midabdomen. Systemic inflammatory response syndrome (SIRS) was observed in this case.

DIAGNOSES

The diagnosis of peritonitis and colonic obstruction secondary to accessory spleen torsion was made. Pathologic examination showed infracted splenic tissue.

INTERVENTIONS

We performed emergency laparotomy and found that accessory spleen torsion pressured against splenic flexure and descending colon, and caused colon obstruction. The patient underwent accessory splenectomy and enteral decompression.

OUTCOMES

At 6 months follow-up, the patient recovered well with perfect digestion.

LESSONS

Accessory spleen torsion and its complications are extremely rare. This entity should be considered in differential diagnosis of acute abdomen. However, in case of acute abdomen with critical clinical situation, emergency surgical intervention is necessary for timely diagnosis and treatment.

Omental torsion: an infrequent cause of abdominal pain

Omental torsion is an infrecuent cause of acute abdomen. It is related to obesity, abdominal surgery and abdominal trauma. Urgent exploratory laparotomy allows diagnosis and prevents complications as intrabdominal abcess. We present CT imaging of a Omenat torsion clinical case.

Bilobate wandering spleen with doble torsion of the vascular pedicle. A case report

INTRODUCTION

Wandering spleen is a rare clinical condition which is often an incidental finding. It is characterized by excessive mobility and displacement of the spleen within the abdomen; although the spleen is usually of normal size it has an elongated vascular pedicle .

CASE STUDY

We present the case of an adult woman who complaining of abdominal pain who was brought to our institution for emergency treatment. She later developed an acute abdomen due to infarction of a wandering spleen caused by double torsion of the vascular pedicle. Emergency splenectomy was performed.

RESULTS

Surgical treatment of a wandering spleen is generally conservative and consists in splenoplexy. In our case, complicated by ischemia leading to irreversible damage of the spleen, splenectomy was the solution.

DISCUSSION

The long vascular pedicle of a migrant spleen is at risk of torsion which can cause irreversible acute ischemia of the spleen. Therefore a timely diagnosis with the use of modern imaging techniques is of primary importance.

CONCLUSIONS

Early interpretation of the symptoms and computed tomography angiography can prevent the complications that result from torsion of the elongated pedicle.

KEY WORDS

Acute abdomen, Bilobate wandering spleen, Splenectomy.

Torsion of a wandering spleen. A rare cause of acute abdomen

Wandering spleen is a rare condition that accounts for less than 0.25% of all indications for splenectomy. It is characterized by ectopic localization of the spleen owing to the lack or weakening of its ligaments. Torsion is the most common complication due to its long pedicle and high mobility, which may result in acute abdomen. We report a case of torsion in a wandering spleen in a 28-year-old male presenting with an acute abdomen that was treated by splenectomy.

The efficiency of endoclips in maintaining the gastrointestinal bleeding-related Dieulafoy's lesion

BACKGROUND

Dieulafoy's lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited.

AIMS

The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL.

PATIENTS AND METHODS

This case series was conducted at Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital. The patients who were admitted to the emergency department of Dıskapı Yıldırım Beyazıt Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS

The median number of endoscopic hemoclips application in first endoscopy was 4 (2-9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery.

CONCLUSIONS

Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Small bowel volvulus due to torsion of pedunculated uterine leiomyoma: CT findings

Torsion of a uterine leiomyoma is a rare complication that can be life threatening because of ischemia or necrosis. This condition may also lead to gastrointestinal complications such as obstruction or, more rarely, small bowel volvulus. Its diagnosis is difficult and can be facilitated with the use of computed tomography or magnetic resonance imaging. Treatment is based on emergency surgical resection of the twisted uterine leiomyoma and detorsion of the small bowel volvulus.

Torsion of a Term Uterus

Torsion of the pregnant uterus, at term, is a very rare event in obstetric practice. It is associated with high perinatal mortality. We are reporting a case of uterine torsion, where a booked second gravida with previous lower segment cesarean section underwent an emergency cesarean section due to severe lower abdominal pain, persistent fetal tachycardia and poor Bishop Score. Following delivery of baby and placenta, uterus untwisted on itself through 180 degrees and it was realized that the incision had been made on the posterior wall of the uterus. Bilateral tubal ligation (BTL) was done after proper informed consent. This decision was based on unavailability of data on safety of future pregnancies in patients with both anterior and posterior uterine scars. Efforts need to be made to develop consensus for management of these cases, in future.

Diagnosis of neonatal ovarian torsion: Emphasis on prenatal and postnatal sonographic findings

PURPOSE

Our aim was to retrospectively review the imaging findings of patients with neonatal ovarian torsion, emphasizing prenatal and postnatal sonographic findings.

METHODS

Eleven patients who had had neonatal ovarian torsion diagnosed surgically (n = 9) or clinicoradiologically (n = 2) were enrolled. Prenatal and postnatal sonographic features, including sequential postnatal change, were reviewed. Clinical and pathologic features were also investigated.

RESULTS

All patients except one had a fetal ovarian cyst (mean, 5.3 cm) detected on third-trimester sonography, either simple (n = 6) or complex (n = 4). In all 11 patients, initial postnatal sonography had revealed a complex cyst (mean, 4.7 cm) with intracystic clot or debris, the double-wall sign, a fluid-fluid level, and multiple septation. None of the patients had had symptoms or signs related to the ovarian torsion. Follow-up sonography in seven patients had revealed increased echogenicity of the cyst wall with frequent calcification and a decrease in size of the cyst. In two patients, the interval of the change in cyst position was noted, and autoamputation of the torsed ovary had been surgically confirmed. Serous cystadenoma had been identified in one patient.

CONCLUSIONS

Neonatal ovarian torsion most commonly manifests as an asymptomatic complex cyst on sonography due to torsion of a fetal ovarian cyst. Serial monitoring of a fetal ovarian cyst for its resolution or changes in its appearance is mandatory for making an early diagnosis of torsion. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:290-297, 2016.

Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Omental torsion, a rare cause of acute abdomen

Omental torsion is a rare cause of acute abdominal pain. We report a case of omental torsion in a 7-year-old girl, who presented with right iliac fossa pain. The patient underwent an open appendicectomy, during which a normal appendix was identified and a diagnosis of omental torsion was made. The affected segment of omentum was resected along with the appendix. The patient made an uncomplicated recovery and was discharged on day 1 postoperatively. A normal appendix in the presence of omental torsion is found in 0.1% of all appendicectomies in children. We suggest routine visualisation of the omentum in the presence of a normal appendix during appendicectomy.