Case of the Month June 2015, Page 4

Answer: 3) Ovary > 4 cm by longest dimension

An enlarged ovary, especially asymmetric enlargement, should raise your suspicion for ovarian torsion. Note that this case is complicated by the patient’s history of PCOS, which also presents with enlarged ovaries and is one condition that can reduce the specificity of using increased ovarian size to detect torsion. The right ovary is larger than the left, demonstrates a heterogeneous and swollen appearance, with follicles pushed further out into the periphery - all signs consistent with ovarian torsion.

Note that presence of both arterial and venous flow do NOT rule out ovarian torsion! Intermittent torsion can cause recurrent acute pelvic pain, and the only sign of this may be a large ovary.

At this point, you are highly suspicious of the possibility of intermittent ovarian torsion, but your decision may send the patient to the operating room, and you want one more piece of conclusive evidence to prove your diagnosis before you make the final call.

Fortunately, you remember to peruse the patient’s medical record, which reveals that the patient has been undergoing evaluation for infertility treatment, and in the process, she underwent a pelvic MRI just four days ago and a hysterosalpingogram (HSG) just two days ago. Jackpot! You take a look at the MR images:

For larger images, please click on Lee9 and Lee10

The first MR image demonstrates an axial (transverse) view demonstrating both left and right ovaries, side by side. The second image demonstrates a coronal (frontal) view of the right ovary.

The MR images solidify your findings, demonstrating that the right ovary is actually larger now on ultrasound than it appeared just four days ago on MR. Not only that, but you note that the signs of ovarian torsion were present even back then -- note that the right ovary is larger than the left and demonstrates peripheralized follicles and a heterogeneous texture. In fact, the possibility of intermittent ovarian torsion had been raised for this patient in the past!

You also decide to take a look at the HSG for completeness’ sake:

For a larger image, please click on Lee11

A hysterosalpingogram is a common procedure used for evaluation of infertility to determine the shape of the inside of the uterus and the fallopian tubes. Contrast is injected through a catheter passing through the cervical canal directly into the uterus to visualize the outlines.

In the prior image, the large central collection of contrast represents the endometrial canal of the uterus. The two thin lines of contrast leading off to each side at the top of the endometrial canal are the fallopian tubes. Note that you can see contrast spilling from both fallopian tubes into the peritoneal cavity: This is normal and indicates that both fallopian tubes are open. Problems such as infection within the fallopian tubes from pelvic inflammatory disease can lead to scarring, blocking the fallopian tubes and potentially leading to infertility.

Curiously, the ampullary portion (the far end) of the right fallopian tube appeared coiled.

Based on your findings, the ED physician consults the gynecology service, who evaluate the patient and take her to the operating room. You later follow up on the operative report, which notes the following findings:

1) Right ovarian torsion, with subsequent de-torsion several times. The ovarian tissue was noted to be pink and not significantly necrotic.

2) Yellow-white pus within the pelvis, consistent with pelvic inflammatory disease! This was suctioned out, and the patient was started on antibiotics.

Remember that although not very common, it is still a possibility that a patient can have two (or more!) concurrent acute diagnoses causing her symptoms. Remember the complex free pelvic fluid seen on ultrasound? It turns out in retrospect that that may have been caused by the pelvic infection. Note that complex free pelvic fluid is not specific to pelvic inflammatory disease and can be caused by other common conditions such as a hemorrhagic cyst, but in combination with the fever and the white blood cell count, it was a strong consideration. The coiled appearance of the ampulla of the right fallopian tube on HSG may have been another hint that an ovarian torsion was present.

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