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Interesting Case Rounds

Interesting Case Rounds. July 19, 2007 Nadim Lalani R4. Case . 13 y F c/o intermittent LLQ/flank pain Began 7am. Pt went back to bed. Pain again at 12 noon. Phoned Healthlink told to go to ACH ER. Waited until 1:30pm. Sharp. Radiating to L flank. No other sympts. Healthy. Premenarchal.

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Interesting Case Rounds

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  1. Interesting Case Rounds July 19, 2007 Nadim Lalani R4

  2. Case • 13 y F c/o intermittent LLQ/flank pain • Began 7am. Pt went back to bed. Pain again at 12 noon. Phoned Healthlink told to go to ACH ER. Waited until 1:30pm. • Sharp. Radiating to L flank. • No other sympts. • Healthy. Premenarchal

  3. DDX? • What will you look for?

  4. P/E: • Initially writhing in pain. Given 50mcg fentanyl and settled somewhat. • Tender L flank. No CVA tender. Not peritoneal. Soft abd. • Ultrasound ordered : • + Torted Ovary w/ multiple cysts, • venous congestion , oedema • absence of arterial flow.

  5. Outcome • Pt eventually went to OR • Or findings, torted normal appearing ovary • Attempt to drain cysts • Pt discharged home

  6. Ovarian Torsion • Intro: • Torsion = twisting of the ovary on its ligamentous supports  often resulting in vasc compromise • 5th MC gyne emergency • Affects all ages • Since sympts can be non-specific  Dx is a challenge

  7. Epidemiology: • 2.7% of gyne surgical emergencies • 80% under 50y, • highest in reproductive ages • increased risk in pregnant and ovarian hyperstimulation

  8. Etiology: • Cysts + neoplasms = 94%  Predispose to swing on pedicle. Larger mass  more risk • 6% normal ovaries • assoc with vigorous excercise • Pathophys: • Compromise of vasc pedicles  impaired blood flow [veins > arteries ]  marked engorgement  ischemia  necrosis  peritonitis

  9. Pathophys

  10. Fetal/Neonatal period: • Rare • Usually because of cysts, rarely neoplsm • Diagnosed on fetal ultrasound • Childhood/Pre-menarche: • Rare [don’t have cysts] • Normal ovaries. • thought to be due to long utero-ovarian ligament

  11. Post-menarche: • Highest risk group • Cysts  neoplasms  infertility treatment

  12. Clinical Picture • Clinical Presentation: • non-specific • Two MC signs are lower abd pain [83%] and adnexal mass [72%] • Neonates: • present w/ in 1st three months • Feeding intolerance, vomiting, abdo distension, fussy/irritable

  13. Children & older: • Acute onset • stabbing lower abd pain  rad to flank/back/groin • assoc w/ waves of N/V • can present w/ peritonitis

  14. Diagnostics • Definitive Dx is OR findings • Doppler Ultrasound:[sens/spec high 90’s] • Visualise adnexal mass + enlarged ovary + hemorrhage + FF • Diminished/absent flow • Nb Normal Ovary doesn’t rule out • Lab: • Serum IL-6

  15. Management • Expeditious surgical consult • Less and less oophorectomy more “watch and wait” [even when dusky] • Fetal [cysts]: • Conservative mgmnt + serial U/S [q4wk] • Neonate [cysts]: • Follow w/ U/S [even neoplasms 1/3 go away] • Cysts < 4cm resolve, >4cm  OR

  16. Children & older: • Early OR as possible [one study only 25% salvage in <15yo] • Unlike testes No Statistically reliable time frame. • Rats 4 hour upper limit  100% salvage. • Recuperation of ovary reported w/ up to 72 hours of torsion • One study median 14h for detorsion  82% had N ovaries on f/u • Delay trends towards less salvage

  17. Prevention? • higher dose BCP? • no difference • Oophoropexy? • Definitely indicated in: • Normal ovary torsion • Oophorectomy [afix the good one so it doesn’t] • some will do with cysts

  18. References Growdon, W and M Laufer. Ovarian Torsion

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