A case report on ovarian cyst torsion: Emergency procedure
Karpagam
OT incharge, Kauvery Hospital, Tirunelveli, Tamil Nadu
Abstract
Ovarian Cyst Torsion is a gynaecological emergency. Definitive diagnosis is sometimes difficult to establish because of clinical symptoms similar to some other abdominal diseases. A 34-year’s old woman P2L2 (NVD) with acute lower left abdominal pain on and off for past 3 days reported to us. Pain aggravated since previous day morning before coming to Emergency department. On physical examination, the abdomen was tender, and a 16 weeks’ size firm mass was felt more to the left side and swelling was present below the gut.
Scan showed: Large multi-septate cyst measuring 9x11x14 cm in the lower abdomen and pelvis more towards right side. No obvious solid component, no calcification or fat density. The patient then underwent an emergency laparotomy, Left Salpingo-Oophorectoy. Histopathologically found compatible with mucinous cystadenoma with focal epithelial proliferation (less than 2 %). The cyst wall showed extensive haemorrhagic changes associated with torsion. There was no intraepithelial/invasive carcinoma. The ovary showed haemorrhage and edema. The fallopian tube showed congestion and no specific pathology. Aspirate cytology smears of cystic fluid showed cyst contents only with cyst macrophages and inflammatory cells. No lining epithelial cells were seen. Negative for malignant cells.
Introduction
Ovarian cyst torsion is a gynaecological emergency but a common diagnostic challenge in emergencies. The varied imaging features and non-specific symptoms of ovarian torsion can lead to delay identification, with misdiagnosis being common. It refers to a complete or partial rotation of the adnexal supporting organ, resulting in ischemic changes in the ovary. Torsion more commonly involves both, the ovary and fallopian tube. In patients undergoing emergency surgery for acute pelvic pain, the frequency of adnexal torsions is about 2.5–7.4%. The gold standard method to confirm and treat ovarian torsion is surgery. There are two surgical methods, laparoscopy and laparotomy.
Case Report
A 34-year-old P2L2 woman came to the Kauvery Hospital Tirunelveli in Emergency room with complaints of acute lower left abdominal pain on and off for three days and the pain aggravated since previous morning before entering the hospital. Pain was felt suddenly and continuously with a pain scale of 6. No other associative complaint nausea, vomiting, and body weakness were present. Fever, vaginal discharge, dizziness, weight loss was denied and patient was conscious and oriented. The patient and her family had no history of previous medical diagnosis or malignancy.
On examination patient was conscious and oriented. The vital signs were stable – patient’s blood pressure 130/90 mmHg, pulse 92/ bpm, respiratory rate 22/bpm, and temperature 98.6F.
Patient weight was 80 kg, height 165 cm, the results of laboratory blood test – haemoglobin level of 11.3 g/dL, leucocytosis with a leukocyte count of 12.800/UL. Computed tomography scan (CT Scan) Abdomen showed large multiseptated cyst in the lower abdomen and pelvis more towards right side.
Figure (1): Ovarian torsion. (a) Longitudinal sonogram showed an enlarged 20×15×15 cm ovary (between cursors labelled A) with peripheral cysts. (b) Power Doppler sonogram showed complete absence of blood flow in the ovary. The pinpoint foci of color in the center of the ovary are secondary to motion artifact.
IVF (RL) was started 100 ml per hour, and Inj. Pan 40 mg, Inj. Diclo, Inj. Para 1 gm given.
On March 29th 2025 laparotomy was performed under spinal Anaesthesia. During the exploration left ovarian cyst of 20x15x15 cm noted and cut section showed multilocalization with reddish mucinous fluid. Left fallopian tube edematous, right fallopian tube, ovary, uterus appear normal. Left Salpingo oophrectomy was performed and the estimated total bleeding is 50cc.
Histopathological examination confirmed compatible with mucinous cystadenoma with focal epithelial proliferation (less than 2 %). The cyst wall showed extensive haemorrhage a change associated with torsion. There was no intraepithelial/invasive carcinoma. The ovary showed haemorrhage and edema. The fallopian tube showed congestion and non-specific pathology. Aspirate cytology smears of cyst fluid show cyst contained only with cyst macrophages and inflammatory cells. No lining epithelial cells were seen. Negative for malignant cells. The postoperative recovery was uneventful.
Discussion
Other Name: Adnexal Torsion
Symptoms: Pelvic pain, Nausea, Vomiting, Fever, non-menstrual vaginal bleeding
Complications: Infertility
Usual onset: Classically sudden
Risk factors: Ovarian cysts, ovarian enlargement, ovarian tumors, pregnancy, tubal ligation
Diagnostic method: Based on symptoms, ultrasound, CT scan, MRI
Differential diagnosis: Appendicitis, kidney infection, kidney stones, ectopic pregnancy
Treatment: Surgery
Frequency: 6 per 100,000 women per year
Ovarian cyst torsion is a complete or partial rotation of the ovarian vascular pedicles which causes obstruction of blood flow. Ovarian cyst torsion can occur at any age with the great incidence in women aged 20-30 years. Our patient’s age was 34 years.
About 70% of ovarian cyst torsion occurs on the right side. This is caused by longer utero-ovary ligaments. On the left side, there is limited space due to the presence of the sigmoid colon also contributes to the incidence of lateralization. Nevertheless, in our patient was found an ovarian cyst torsion on the left side. Ovarian cysts more than 5 cm have a risk of becoming torsion. The other risk factors of ovarian cyst torsion are pregnancy, ovarian stimulation history of abdominal surgery and tubal ligation. Ovarian cyst torsion is also associated with ovarian pathology such as dermoid cyst which caused enlargement of the ovaries. Intraoperative evaluation in this patient found a cyst measuring 20x15x15 cm, which is the risk factor for ovarian cyst.
The diagnosis of ovarian cyst torsion tends to be difficult because of clinical parameters with low sensitivity and specificity. Abdominal pain is reported in most patients with ovarian cyst torsion. Such as acute pain occurs in 59-87% of cases, colic pain in 70%, and pain radiating to the pelvis, back or groin in 51% of them. Patients with incomplete torsion can experience severe pain with asymptomatic episodes. Nausea and vomiting often occur in 59-85% of cases and subfebris in 20%. Other nonspecific symptoms include non-menstrual vaginal bleeding and leukocytosis, each reported around 4.4% and 20% of cases, respectively. This patient had acute abdominal pain, and leukocytosis.
Many signs and symptoms of ovarian cyst torsion are associated with other conditions including Pelvic Inflammatory Disease, Tubal Ovarian Abscess, Ovarian Cyst Rupture, Acute Appendicitis, and Ectopic pregnancy. Ovarian cyst torsion must be a differential diagnosis because in this case it can cause loss of functions and effects of other sequels without prompt and adequate therapy.
Routine blood evaluation of acute pelvic pain is carried out to detect evidence of infection, anaemia, and inflammation. There are no specific markers in diagnostic accuracy in adnexa torsion. The most common marker examined is the C-reactive protein that appears in acute-phase inflammation. Leukocyte levels are also frequently measured and increased in about 50% of women with adnexa torsion. The cause of infection is ruled out due to the absence of supporting clinical symptoms, such as fever.
Pelvic ultrasonography is the first supporting examination for patients with suspected ovarian cyst torsion. The ultrasonography grayscale description of ovarian cyst torsion is unilateral ovarian enlargement > 4 cm, pearl strands sign, the coexistence of the mass in the ovary is bent, free of pelvic fluid and torsion vascular pediculus. Doppler ultrasound is also used as a diagnostic tool for ovarian cyst torsion. The presence of flow in Doppler does not exclude torque but shows that the ovaries are viable.
Ultrasonography is cheaper. MRI or CT scan be done if the results of an ultrasound examination are not clear. Focus therapy for ovarian cyst torsion is to maintain ovarian function and prevent other side effects such as bleeding, peritonitis, and adhesion formation. Oophorectomy is performed only on necrotic/gelatinous tissue. Studies shows that torsion release is associated with the return of ovarian function in some patients, emphasizing the importance of prompt intervention.
Laparoscopy is a selective procedure with many benefits, including a lower risk of wound complications, less pain and postoperative ileus, shorter hospitalization, reduced adhesion formation, and faster return to normal activities. Follow-up for women who have undergone detorsion or ovarian torsion release shows recovered ovarian function, as evidenced by follicular activity on ultrasound, pregnancy rates, response to ovulation induction or findings on subsequent laparoscopy.
Conclusion
Ovarian cyst torsion can occur at any age. Therefore, a high index of suspicion coupled with radiographic evidence and adequate clinical presentation reduces morbidity and complications of the disease. Rapid diagnosis and surgical intervention are the keys to recovery.
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