16 August 2021: Articles
Mistake in diagnosis, Diagnostic / therapeutic accidents, Management of emergency careMaram Aljohani1ABDE, Muna Aljahany2DEF*, Sarah Yousif Elbasheer1BDE, Maha Bandar AboWadaan2EF, Osama Kentab1DE
Am J Case Rep 2021; 22:e932245
BACKGROUND: Ovarian torsion is a rare surgical emergency in premenarchal girls. Early diagnosis and surgical detorsion are required to restore blood flow and limit tissue damage.
CASE REPORT: Here, we present a case of ovarian torsion and appendicitis in an 11-year-old premenarchal girl who presented to our emergency room with a 4-day history of right iliac fossa pain, limping, and fever. Upon initial evaluation in our hospital, her vital signs were stable and clinical examination revealed abdominal guarding and right lower quadrant rebound tenderness with positive Rovsing’s sign. Abdominal ultrasound and computed tomography scans showed adnexal cysts and torsion, an inflamed appendix, and free fluid in the abdomen. Intraoperative findings included a twisted gangrenous ovary and an edematous appendix. The patient underwent emergency laparoscopic oophorectomy and appendectomy.
CONCLUSIONS: This case demonstrates that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary.
Keywords: Adolescent, appendicitis, Ovary, Appendectomy, Child, delayed diagnosis, Ovarian Torsion, Torsion Abnormality
Ovarian torsion is defined as a rare gynecologic emergency occurring as the ovary twists on its ligamentous support, which obstructs the blood flow to the ovaries. There is no specific diagnosis of this condition in the form of clinical presentation in pediatric cases. Moreover, there might be inconsistency or equivocality in diagnostic imaging through computed tomography, magnetic resonance imaging, and Doppler ultrasound . The occurrence of ovarian torsion is rare among children and adolescents; however, it is important to consider pediatric females with abdominal pain.
Approximately 2 out of 10 000 pediatric and adolescent populations are affected by this disease, which constitutes 15% of all torsion cases . The occurrence of torsion is observed among pre-and post-menarchal girls.
Adnexal torsion can affect otherwise healthy ovaries, known as torsion of the normal adnexa, or pathologic adnexa, which typically contains ovarian or para-ovarian cysts. Among the pediatric and adolescent populations, most of the torsion cases (40–84%) develop because of some ovarian pathology, whereas other cases demonstrate torsion of normal adnexa [3,4]. It is expected that torsion in post-menarchal teens is linked with functional ovarian cysts like the cysts of the corpus luteum .
The risk of recurrent torsion is associated with the underlying pathology that causes torsion. Previous studies have shown that 60% of the recurrence rate in pre-and post-menarchal females is associated with normal adnexa [6,7]. Moreover, these cases present a chance of preventing recurrent torsion by ovarian fixation of the ipsilateral and bilateral adnexa .
Here, we describe an uncommon case of a delayed diagnosis of ovarian torsion complicated by reactive appendicitis.
Consent was obtained from the parents of the patient before continuing with this case study.
An infrequent cause of abdominal pain arises as the result of ovarian torsion among the pediatric female population. There is a rare occurrence of ovarian torsion with concomitant appendicitis. Physical exam ultrasonography, radiographs, and computed tomography are used as a diagnostic modality for these patients . The outcomes seem to be good in patients who undergo appendectomy and oophorectomy with or without a salpingectomy. A cystic ovarian lesion is present in 5 out of 7 cases, while 1 out of 7 cases present with ovarian neoplasm in pathologic analysis. The present case is unique, with no identification of coexisting ovarian pathology.
Previous studies have shown that sonography and computed tomography are widely used for the diagnosis of ovarian torsion [10,11]. The major ultrasonic signs of the development of ovarian torsion include multiple follicles in cortical portions of the ovary and pelvic masses that may be with or without fluid in the pouch of Douglas . In the present case, there was no flow to the torsed ovary observed through duplex imaging. It is possible to differentiate between appendicitis and ovarian torsion through ultrasonography with color Doppler. The 2 main issues highlighted by the present case study are that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary, and that adnexal torsion should be considered in the differential diagnosis of reactive appendicitis, and a surgeon skilled in managing both conditions should be consulted.
A similar case study by Al-Turki  described a delayed diagnosis of ovarian torsion in a patient presenting with vomiting and sudden onset of right iliac fossa pain. On initial examination, the patient was tender in the right iliac fossa but without rebound tenderness; therefore, an initial diagnosis of appendicitis was made. However, after 17 hours of delay, this case was successfully managed with detorsion of the ovary after clinical imaging revealed a normal appendix. This case demonstrated the overlapping clinical features of appendicitis and ovarian torsion.
Another cause of a reproductive-age woman was presented by Callen et al , who presented with a history of sub-acute lower abdominal pain that became worse with physical activity, and a low-grade fever. Ultrasound revealed an edematous ovary but ovarian torsion was considered unlikely. However, magnetic resonance imaging (MRI) confirmed a twisted vascular pedicle and demonstrated a markedly dilated, hyper-enhancing appendix with extensive inflammatory changes involving the surrounding peritoneal fat as well as the small and large bowel. Abdominal examination revealed minimal periumbilical tenderness without any guarding or rebound tenderness. She consented to diagnostic laparoscopy for possible appendectomy; however, the intraoperative assessment revealed features of chronic appendicitis with dense adhesions precluding safe appendectomy. The ovary was edematous due to inflammation from chronic appendicitis without any torsion or ovarian mass. In conclusion, this was ovarian edema due to adjacent appendicitis .
A rare case of pediatric ovarian torsion in a premenarchal 13-year-old girl was reported by Rajwani and Mahomed . This case presented with engorged massive edematous and hemorrhagic ovarian torsion treated with salpingo-oophorectomy. This case was similar to our own in having a clinical presentation with features of acute appendicitis and similar histopathology results.
Adnexal torsion is most common among women aged 20–30 years . Even though adnexal torsion is rare in premenarchal girls , it should be ruled out in patients presenting with signs and symptoms of an acute abdomen, such as those with suspected renal colic and acute appendicitis. Distinguishing between these 2 clinical entities may be challenging due to the overlapping signs and symptoms; therefore, ultrasound should be obtained to confirm the clinical diagnosis and prevent misdiagnosis. According to a previous study , young girls presenting with lower abdominal pain should undergo an ultrasound to rule out adnexal torsion and prevent potentially irreversible damage to the ovaries. In our case, ovarian torsion was evident on ultrasound; however, a previous study reported that ultrasound was insufficient to detect ovarian torsion in a woman of reproductive age . However, our patient also underwent a CT scan to confirm the diagnosis, which highlights the need for further research to evaluate whether ultrasound should always be complemented by more detailed imaging modalities such as CT or MRI.
The coincidence of ovarian pathology with appendicitis is rare; however, it can require surgery in some pediatric female patients. It is often possible to secure the torsioned ovary, but there is a need to perform ovarian sparing whenever possible. The present case reveals that ovarian torsion accompanied with appendicitis often requires salpingo-oophorectomy along with an appendectomy.
Ovarian torsion in pediatric patients has a similar clinical presentation and may be treated by laparoscopy in most cases. This present case study showed that reactive appendicitis can occur secondary to inflammation of adjacent structures such as the ovary. It is shown that there is an increased risk of torsion recurrence among premenarchal girls with torsion involving normal adnexa that should be followed accordingly. This case highlights the need for further studies to evaluate the sensitivity and specificity of ultrasound alone in detecting complicated adnexal torsion in adolescent girls.
FiguresFigure 1.. Coronal view of the abdominal and pelvic CT with intravenous contrast showing (A) an appendix with a thickened enhancing edematous wall in the right iliac fossa measuring about 10 mm in diameter; (B) moderate free fluid in the right iliac fossa, hepatorenal pouch, and pelvic region; (C) right adnexal cystic structure with septation, hyperdense component, and thickened wall, measuring about 6.5×4.8 cm. Figure 2.. Axial view of the abdominal and pelvic CT with intravenous contrast showing (A) an appendix with thickened enhancing edematous wall in the rightiliac fossa measuring about 10 mm in diameter; (B) moderate free fluid in the right iliac fossa, hepatorenal pouch, and pelvic region; (C) right adnexal cystic structure with septation, hyperdense component, and thickened wall, measuring about 6.5×4.8 cm.
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