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

Computed Tomography Features of Adnexal Torsion: A Meta-Analysis

OBJECTIVES

We performed a meta-analysis of studies examining the computed tomography (CT) features of adnexal torsion (AT).

METHODS

We searched PubMed, Embase, Web of Science, and the Cochrane Library for studies involving the proportion of CT features in patients with AT and that used surgery as the reference test. Study quality was assessed using the Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality tool.

RESULTS

Twelve articles involving 483 patients were included. The pooled proportion of right-sided adnexal lesion was 54% (95% confidence interval [CI]: 49%-56%). The pooled proportions of the ovarian lesion histopathological types were: benign germ cell tumors, 33% (95% CI: 28%-37%); benign cystic lesions, 26% (95% CI: 21%-30%); benign epithelial neoplasms, 24% (95% CI: 20%-29%); sex cord-stromal tumors, 4% (95% CI: 2%-6%); borderline neoplasms, 3% (95% CI: 1%-6%); and hemorrhagic cysts, 2% (95% CI: 0%-3%). The pooled proportions of CT features were: Adnexal enlargement, 99% (95% CI: 98%-99%); adnexal with mass, 98% (95% CI: 97%-100%); twisted pedicle, 81% (95% CI: 78%-83%); mass with thickened wall, 77% (95% CI: 73%-81%); tubal thickening, 73% (95% CI: 68%-77%); abnormal location of adnexa, 69% (95% CI: 63%-75%), pelvic ascites, 43% (95% CI: 38%-49%); pelvic fat infiltration, 41% (95% CI: 34%-48%); uterine deviation, 37% (95% CI: 31%-42%); and lack of enhancement, 20% (95% CI: 14%-25%).

CONCLUSION

Adnexal enlargement, adnexal mass, and twisted pedicle may be the most important CT features for diagnosing AT.

Laparoscopic Salpingectomy for an Isolated Case of Left Fallopian Tube Torsion in a Premenarcheal 13 years old

Isolated torsion of the fallopian tube without an ovarian abnormality is an uncommon clinical finding even rarer before menarche and postmenopause, with an incidence of approximately 1 in 1.5 million women. Left fallopian tube torsion is infrequent as compared to right. Here, we report a rare case of a prepubertal girl who presented with acute left abdominal pain. Ultrasound suggested normal ovaries, and a significant left hydrosalpinx and color-Doppler was done, which confirmed signs of left-sided fallopian tube torsion. On laparoscopy, her left fallopian tube was twisted around its axis five times with the signs of necrosis, a laparoscopic salpingectomy was performed. Laparoscopy is the gold standard for the diagnosis and management of this condition. A high index of suspicion is necessary to make an early diagnosis allowing conservative surgical management and hence fertility preservation.

Significant elevation in serum CA 125 and CA 19-9 levels with torsion of the hydrosalpinx in a postmenopausal woman

Isolated torsion of the fallopian tube in postmenopausal women is rare. In this case report, we detail the case of a 53-year-old patient who presented with adenomyosis and a left hydrosalpinx with high levels of CA 125 and CA 19-9. The isolated torsion of the left hydrosalpinx was observed during the operation. The serum levels of CA 125 and CA 19-9 were reduced from 129.62 and 348 to 58.2 and 12.41 U/mL, respectively, after total laparoscopic hysterectomy with salpingectomy. On radiologic evaluation, there were no other factors that may have influenced the increase in serum levels of CA 125 and CA 19-9 in this patient, which were reduced after operation. To the best of our knowledge, this is the first case of association between perioperative changes in CA 19-9 levels and isolated torsion of the fallopian tube.

Gynecological pelvic pain as emergency pathology

Acute pelvic pain is a common condition in emergency. The sources of acute pelvic pain are multifactorial, so it is important to be familiar with this type of pathologies. The purpose of this article is review the main causes of gynecological acute pelvic pain and their radiologic appearances to be able to make an accurate diagnosis and provide objective criteria for patient management.

Isolated Fallopian Tube Torsion With Fimbrial Cyst In A 10 Year-old Girl Diagnosed By Ultrasound: A Case Report

Torsion of the fallopian tube without the involvement of the ipsilateral ovary is a rare but important cause of acute abdominal pain in women as it is a surgical emergency. Although uncommon, it should be considered as one of the differential diagnosis in female children presenting with acute lower abdominal or pelvic pain. The diagnosis of isolated fallopian tube torsion is difficult pre-operatively and is often made during laparoscopic or surgical exploration because diagnostic features are usually non-specific. In this report, we present a case of isolated fallopian tube torsion with fimbrial cyst in a young female patient diagnosed pre-operatively by ultrasound.

Magnetic resonance imaging of acute abdominal and pelvic pain in pregnancy

Evaluation of acute abdominal and pelvic pain in pregnancy presents a diagnostic challenge for clinicians and radiologists alike. The differential diagnosis includes obstetric and nonobstetric conditions unique to pregnancy, in addition to causes of acute abdominal and pelvic pain unrelated to the pregnancy. The clinical presentation and course of disease may be altered in pregnancy, and several pathologies are exacerbated by pregnancy. Discriminating clinical features in the diagnosis of abdominal and pelvic pain are often confounded by expected anatomic and physiologic changes in pregnancy. Moreover, while diagnostic pathways may be altered in pregnancy, the necessity for a timely and accurate diagnosis must be underscored, as delay in treatment may result in an undesirable increase in morbidity and/or mortality for both the patient and fetus. Advances in magnetic resonance imaging (MRI) through faster acquisition and motion-insensitive techniques, coupled with increased awareness and education regarding the value of MRI in diagnosing a wide range of pathology, have established MRI as a valuable strategy in the investigation of acute abdominal and pelvic pain in the pregnant patient. This review presents a practical approach to common obstetric and nonobstetric causes of acute abdominal and pelvic pain during pregnancy, as well as safety considerations for performing MRI in this patient population.

Fallopian tube torsion in the pediatric age group: radiologic evaluation

Fallopian tube torsion is a rare but important cause of acute pelvic pain in young adolescent girls. It is a surgical emergency treated with either detorsion or salpingectomy. The imaging findings can be nonspecific and challenging. However, an accurate early diagnosis is essential for prompt surgical treatment. Our objective was to review whether imaging findings can be specific enough to suggest the diagnosis of tubal torsion prospectively in the appropriate clinical setting. An Institutional Review Board-approved retrospective review of our imaging database from 2005 to 2012 revealed 10 surgically proven cases of fallopian tube torsion. All cases had sonography performed; 5 cases had additional multidetector computed tomography. All 10 patients (9-17 years) presented with acute pelvic pain. Sonographic findings included dilated tubular structures in 6 of 10 cases: adjacent to a normal ipsilateral ovary in 5 of 6 and adjacent to a benign ovarian teratoma in 1. In 4 cases, no dilated tube was identified; 3 of 4 had a cystic mass separate from the ovaries, and 1 had the imaging appearance of a multicystic ovary. Computed tomographic findings in the 5 cases that underwent multidetector computed tomography included a dilated tubular structure in 3 of 5; 2 of 5 had a cystic adnexal mass identified. Although rare, tubal torsion should be considered in female adolescents with acute pelvic pain. Sonography should be the first imaging choice. When a tubular structure or a midline cystic mass associated with a normal ipsilateral ovary is noted, tubal torsion should be considered in the differential diagnosis.

An uncommon twist: isolated fallopian tube torsion in an adolescent

We report a 13-year-old girl with bilateral paratubal cysts and left isolated fallopian tube torsion (IFTT). Paratubal cysts are uncommon in children, and IFTT is a rare complication. Awareness of this entity and prompt surgical intervention could potentially salvage the fallopian tube preserving fertility.

Isolated fallopian tube torsion

Isolated torsion of the Fallopian tube is a rare gynecological cause of acute lower abdominal pain, and diagnosis is difficult. There are no pathognomonic symptoms; clinical, imaging, or laboratory findings. A preoperative ultrasound showing tubular adnexal masses of heterogeneous echogenicity with cystic component is often present. Diagnosis can rarely be made before operation, and laparoscopy is necessary to establish the diagnosis. Unfortunately, surgery often is performed too late for tube conservation. Isolated Fallopian tube torsion should be suspected in case of acute pelvic pain, and prompt intervention is necessary.

Value of intra-adnexal and extra-adnexal computed tomographic imaging features diagnosing torsion of adnexal tumor

OBJECTIVE

The objective of this study was to evaluate the usefulness of the intra-adnexal and extra-adnexal computed tomographic (CT) features in identifying adnexal torsion.

PATIENTS AND METHODS

We retrospectively analyzed CT examinations of 38 adnexal masses with torsion and 270 without torsion, which has been surgicopathologically confirmed. The CT features were evaluated according to 2 categorized groups. The first group included the intra-adnexal features dealing with the ovary and uterine tube, whereas the other included the extra-adnexal features dealing with changes of adjacent anatomical structures such as the uterus, gonadal vein, and peritumoral zone. We acquired statistical proportions for the frequencies of these 2 groups of CT features in ovarian tumors with adnexal torsion versus those without adnexal torsion.

RESULTS

When there were intra-adnexal CT features of adnexal torsion, peculiar uterine tube thickening was identified in 74% of the lesions, eccentric or concentric wall thickening in 54% (of only cystic lesions), eccentric septal thickening in 50% (of only cystic lesions except mature cystic teratoma), and eccentric or diffuse decreased or poor contrast enhancement of the internal solid component or thickened wall in 50%. In extra-adnexal CT features of adnexal torsion, uterine deviation to the twisted side was identified in 61% of the lesions, peritumoral infiltration in 40%, nonvisualized anatomic continuity of the ipsilateral gonadal vein with the twisted adnexal mass in 71%, and ascites in 13%. There were significant differences in all of the intra-adnexal and extra-adnexal CT findings, except for ascites, between twisted and nontwisted adnexal tumors.

CONCLUSIONS

The intra-adnexal and extra-adnexal groups of CT features are valuable in identifying torsion of adnexal mass.

Isolated fallopian tube torsion with pregnancy- a case report

Isolated torsion of the fallopian tube occurring in pregnancy is very rare. This entity should be considered in the differential diagnosis of acute pelvic pain with cystic adnexal mass associated with a normal ipsilateral ovary. This is a case report of a primi gravida at 29 weeks of pregnancy who was presented with isolated fallopian tube torsion.

Isolated torsion of the fallopian tube in a menarchal 11-year-old girl

Isolated torsion of the fallopian tube is a rare cause of an acute lower abdominopelvic pain in adolescent females that is difficult to recognize preoperatively. This is a case report of an 11-year-old girl who presented with a right lower quadrant abdominal pain, nausea, and vomiting secondary to isolated torsion of the right fallopian tube 2 days after the onset of her first menses. In this report, the patient's clinical course is discussed with special emphasis on diagnostic imaging and management strategy of adnexal torsion in pubertal and adolescent girls.

CT Features of Adnexal Torsion

OBJECTIVE

Adnexal torsion is most commonly a clinical diagnosis, often aided by sonographic findings. At times, the clinical presentation can mimic nongynecologic causes of acute lower abdominal pain. In these cases, CT may be the initial imaging study. The purpose of this study was to define the CT features associated with adnexal torsion.

CONCLUSION

On CT, a well-defined adnexal mass abnormally located in the pelvis with ipsilateral deviation of the uterus in a woman or girl with lower abdominal pain should raise the suspicion of adnexal torsion. Inflammatory signs on CT suggest the presence of necrosis.

Spontaneous detorsion of the ovary: can it be diagnosed by MRI?

PURPOSE

To determine whether recent progress in imaging has made it possible to diagnose spontaneous detorsion, which is an accepted concept in the gynecological literature but until now has been a presumptive diagnosis that could not be confirmed because of the lack of imaging proof.

MATERIALS AND METHODS

We searched for patients who had a diagnosis of spontaneous detorsion on MRI between January 2000 and January 2003, and selected only patients who met a selection of strict criteria, including mainly enlargement and hyperintensity of ovarian stroma on T2-weighted (T2W) images, clinical findings compatible with torsion and detorsion, and return of the stroma to normal size on follow-up examinations. Other signs of torsion, such as tubal thickening, were appreciated but not mandatory. Clinical follow-up for at least three years was available.

RESULTS

Four patients met the study criteria. No stabilizing procedure was performed in the ovaries. One patient recurred and lost her ovary.

CONCLUSION

The diagnosis of torsion followed by spontaneous detorsion was made with high probability in a selected number of patients. The clinical management of such patients remains a matter of debate. Laparoscopy with oophoropexy would be useful for young patients in whom close follow-up cannot be achieved.

Paratubal and tubal abnormalities

The fallopian tubes are the essential genital ducts that convey the female sex cells for fertilization. They are differentiated and detectable early in fetal life. There are numerous paratubal and tubal abnormalities that can occur at any point in the female life. Some of these are rare but may initiate significant morbidity and/or manifest as life-threatening clinical problems. A comprehensive understanding of symptoms, diagnosis, optimal imaging modalities, and medical and surgical management is vital to identify the best treatment option. The clinical entities described in this article include torsion, hydatids of Morgagni, paraovarian cysts, infections including tuboovarian abscess/pyosalpinx and salpingitis isthmic nodosa, ectopic pregnancy, tumors, and genetic disorders.

Paratubal cyst complicated by tubo-ovarian torsion: Computed tomography features

Paratubal cysts complicated by tubo-ovarian torsion are an uncommon cause of acute right iliac fossa pain in children and very rarely diagnosed accurately preoperatively. We report a constellation of diagnostic CT features in a 12-year-old pubertal girl.

Acute torsion of uterine leiomyoma: CT features

Acute torsion of a subserosal leiomyoma is a rare acute condition that is infrequently diagnosed preoperatively. It is a recognized surgical emergency, especially when additional systemic symptoms are associated. There are two main differential diagnoses: ovary/adnexal torsion and massive infarct inside a common leiomyoma. The diagnosis can be established by computed tomographic features. Ultrasound examination is less sensitive.

Adnexal torsion: Magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance

PURPOSE

To evaluate ultrasound (US) and magnetic resonance (MR) findings in the viable twisted adnexa.

MATERIALS AND METHODS

Ten patients underwent US and MR studies before surgical detorsion. Corrected cross-sectional area of the ovary was defined as cross-sectional area minus areas of cysts and follicles superior to 1 cm. On T2-weighted images, signal intensity of the stroma was graded as type 1 when it was equal to that of urine and type 2 when it was less than that of urine but markedly more than the contralateral side.

RESULTS

The tube was twisted in six cases and the ovary in nine cases. All adnexa were viable. The largest ovarian cross-sectional area and the largest corrected ovarian cross-sectional area of the twisted ovary were significantly larger than those of the contralateral ovary (P = 0.043 for US; P = 0.012 and 0.017, respectively, for MR). These ovaries contained types 1 and 2 hyperintensity in six cases and only type 2 hyperintensity in three cases. Tubal thickening was seen on MR in five cases.

CONCLUSION

Tubal thickening, enlargement of ovarian stroma as reflected by the corrected cross-sectional area, and hyperintensity of this stroma on T2-weighted images probably related to edema were useful findings in these viable torsions.

Massive ovarian edema revealing gastric carcinoma: a case report

Tumor-like enlargement of the ovaries due to accumulation of edema fluid within the ovarian stroma is referred to as massive ovarian edema (MOE). The pathogenesis of MOE is thought to be intermittent torsion of the ovary on its pedicle, causing partial obstruction of venous and lymphatic drainage. The diagnosis of MOE is based on imaging techniques. The case described here due to ovarian lymphatic vessel obstruction by carcinoma cells shows that metastatic disease may be a cause of MOE.

CT and MR imaging features of adnexal torsion

In adnexal torsion, the ovary, ipsilateral fallopian tube, or both twist with the vascular pedicle, resulting in vascular compromise. Unrelieved torsion is likely to cause hemorrhagic infarction as the degree of arterial occlusion increases. Therefore, early diagnosis is important to preserve the affected ovary. Adnexal torsion commonly accompanies an ipsilateral ovarian neoplasm or cyst but can also occur in normal ovaries, usually in children. Although ultrasonography is typically the initial emergent examination, computed tomography (CT) and magnetic resonance (MR) imaging may also be useful diagnostic tools. Common CT and MR imaging features of adnexal torsion include fallopian tube thickening, smooth wall thickening of the twisted adnexal cystic mass, ascites, and uterine deviation to the twisted side. Uncommon imaging findings in adnexal torsion that are specific to hemorrhagic infarction include hemorrhage in the thickened fallopian tube, hemorrhage within the twisted ovarian mass, and hemoperitoneum. Additional imaging findings that can suggest hemorrhagic infarction include eccentric smooth wall thickening exceeding 10 mm in a cystic ovarian mass converging on the thickened fallopian tube and lack of contrast enhancement of the internal solid component or thickened wall of the twisted ovarian mass. Early diagnosis can help prevent irreversible structural damage and may allow conservative, ovary-sparing treatment.

Isolated tubal torsion managed laparoscopically

Adnexal cystic lesions in women of reproductive age are common. Most are functional ovarian cysts, followed by paraovarian cysts, hydrosalpinx, and adnexal torsion. A 34-year-old woman experienced mild abdominal pain, nausea, and low-grade fever. She received empiric antibiotics in an outpatient clinic after a diagnosis of tubo-ovarian abscess. After 3 days she was referred to our hospital with no improvement in symptoms or signs. Isolated fallopian tube torsion was diagnosed and successfully treated by laparoscopy. Laparoscopy played an important role in making an accurate diagnosis and avoiding unnecessary delays in treatment.

MR imaging in pelvic inflammatory disease: comparison with laparoscopy and US

PURPOSE

To assess the value of magnetic resonance (MR) imaging in the diagnosis of pelvic inflammatory disease (PID) and to compare MR imaging with transvaginal ultrasonography (US) and laparoscopy.

MATERIALS AND METHODS

Thirty consecutive patients hospitalized because they were clinically suspected of having PID underwent transvaginal US and T1-weighted spin-echo, T2-weighted turbo spin-echo, and inversion-recovery MR imaging at 1.5 T. All patients underwent laparoscopy after MR imaging.

RESULTS

PID was laparoscopically proved in 21 (70%) patients. The MR imaging diagnosis agreed with that obtained with laparoscopy in 20 (95%) of the 21 patients with PID. The imaging findings for PID were as follows: fluid-filled tube, pyosalpinx, tubo-ovarian abscess, or polycystic-like ovaries and free pelvic fluid. Findings at transvaginal US agreed with those at laparoscopy in 17 (81%) of the 21 patients with PID. The sensitivity of MR imaging in the diagnosis of PID was 95%, the specificity was 89%, and the overall accuracy was 93%. For transvaginal US, the corresponding values were 81%, 78%, and 80%.

CONCLUSION

MR imaging is more accurate than transvaginal US in the diagnosis of PID and provides information about the differential diagnosis of PID. MR imaging may reduce the need for diagnostic laparoscopy.

Torsion of the fallopian tube: progression of sonographic features

Isolated torsion of the fallopian tube is a rare gynecologic condition that is difficult to diagnose preoperatively. We present the sonographic and CT findings over a 48-hour period in a case of isolated torsion of the fallopian tube. The radiologic features of isolated torsion have been described previously; however, to our knowledge, the progressive findings have not been previously reported.