Isolated Fallopian Tube Torsion: An often missed diagnosis

Isolated Fallopian Tube Torsion: An often missed diagnosis Poster No.: R-0002 Congress: RANZCR-AOCR 2012 Type: Educational Exhibit Authors: G. McKenzie; Brisbane/AU Keywords: Surgery, Ultrasound, CT, Genital / Reproductive system female, Abdomen, Acute DOI: 10.1594/ranzcraocr2012/R-0002 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. www.ranzcr.edu.au Page 1 of 14

Learning Objectives Acute pelvic and abdominal pain is a common clinical problem in women; which is caused by a number of different pathologies and often involves referral for medical imaging, either by ultrasound (US) or computed tomography (CT). Imaging is particularly important 3 in these patients for ruling out ovarian/adnexal pathology or non viable pregnancy. However, even with modern imaging techniques the cause of acute abdominopelvic pain may not be clear, which not only presents a diagnostic conundrum but can delay emergency surgery and increase the risk of complications. We present a case involving of a young woman with an isolated fallopian tube torsion that was not diagnosed on ultrasound or repeat CT; final diagnosis was made at emergency laparotomy after perforation. This case serves to illustrate the importance of adding adnexal/ovarian to our list of differentials when imaging women with abdominopelvic pain. Background Case Report A 27 year old gravida 0 and para 0 woman presented to the emergency department with a one day history of increasing left flank pain and fever. The pain came on suddenly without obvious cause, rated a 5/10 in severity and did not radiate. The pain came in waves and the patient had experienced a similar episode 1 year ago. She denied nausea, vomiting or other associated symptoms. The pain worsened over 3 days, becoming more diffuse and rd constant. The patient also developed significant nausea and at the 3 day had signs of peritonitis. She described no significant medical or surgical history apart from an episode of anaemia in 2004. She was sexually active but denied a history of sexually transmitted infections, although she admitted occasions of not using barrier contraception and had notable episodes of discharge in the past. Despite this, the patient had a history of regular gynaecological exams and normal pap smears and denied ever having been pregnant. On examination in the patient was obese, afebrile and had normal vital signs. Her left flank was tender, both directly and on transmission when palpating the right side. There were no peritonisms (initially) and no mass could be palpated confidently owing to the size of her abdomen. A Full blood count showed anaemia, similar to her previous episode of anaemia in 2004. White cell counts, liver function tests and electrolytes were all normal and serum beta human chorionic gonadotropin was negative. Urinalysis was positive for leukocytes, bacteria and blood but showed contamination with a number of epithelial cells present. Differentials at this stage included renal calculi, pyelonephritis, diverticulitis, appendicitis, pelvic inflammatory disease, and haemorrhagic ovarian cyst. Page 2 of 14

Because of a high suspicion of renal calculi the patient was sent for an abdominal CT (Fig. 1, 2), which revealed a large cystic mass, measuring 25.6 cm by 19.6 cm in the coronal plane, sitting within the central abdomen. The mass had its inferior aspect abutting against the bladder and uterus but the relationship between the mass and the ovaries was poorly demonstrated. The mass was large enough to displace part of the large and small bowel and was located inferiorly to the transverse colon and anteriorly to the small bowel. It also pushed against the posterior aspect of the umbilicus and the appendix in the right iliac fossa. Differential diagnoses now included a large mesenteric or ovarian mass/cyst and ovarian torsion, however due to the size of the mass and the inability to determine its origin an ultrasound scan (US) was performed. Ultrasound (Fig. 3) showed a large cystic mass on the right side of the patients abdomen that measured 23 x 13.7 x 22.5 cm, was avascular and appeared to be separate from the ovaries. The left ovary measured 8 ml and the right measured 13 ml, both were unremarkable and both had normal arterial and venous flow. No focal lesion was identified in the ovaries or in the adnexa, the uterus appeared normal. The mass was cystic in appearance and was associated with a trace of free fluid in the pouch of Douglas. Both kidneys were normal and the appendix was not appreciable. Due to the inability to define the origin of the mass on US and the patient's ongoing/ worsening symptoms, a contrast enhanced abdominal CT was performed (Fig. 4, 5). The repeat CT again showed a well-defined cystic lesion, measuring 23.6 x 19.4 cm, in the right lower abdomen that was unchanged in appearance compared to the two previous imaging modalities and that had no obvious internal septations or calcifications. There were no focal solid components to the mass but again a small amount of free fluid was present in the abdomen. Still no relationship between the mass any abdominal/pelvic structures was found other than a mass effect where the lesion was seen to displace surrounding structures. Further differentials at this time included a mesenteric inclusion cyst, urachal cyst, and cystadenoma of the appendix. Due to the lack of a definitive diagnosis at this point, despite multiple imaging studies, an elective laparoscopy was planned for 2 weeks' time. However, over the next 3 days the patient's symptoms worsened and developed into an acute abdomen with the development of peritonisms and a rapid drop in the patient's haemoglobin and blood pressure. The patient was subsequently taken to theatre for exploratory laparotomy that showed a large cystic mass distinct from the colon, small bowel and appendix with turbid free fluid noted in the abdomen. On delivering the mass outside of the abdomen it became 0 apparent that the cause of the pathology was a 360 isolated torsion of the left fallopian tube (Fig. 6). An inflamed uterus was also noted suggesting pelvic inflammatory disease. An ovary sparing salpingostomy was performed and the patient was placed on empirical antibiotics discharged from hospital 10 days after admission. Page 3 of 14

Discussion Ovarian or adnexal torsion is an uncommon but likely underdiagnosed medical emergency due to twisting of the ovary and or fallopian tube and was first described 1,2 by Bland-Sutton in 1890. Isolated Fallopian tube torsion (IFTT) is much rarer still and occurs in around 1/1,000,000 women, although because of its rarity this number is 1,3,4,5 difficult to estimate. IFTT presents non-specifically with sudden lower abdominal/ pelvic pain; which can be dull or sharp, constant or intermittent but is most often a colicky 1,4 pain and can radiate to the groin, flank or thigh. Other features of IFTT include a palpable mass, peritonisms (guarding, rebound and rigidity) and with marked nausea 3-6 and vomiting. Pelvic exams may be normal or show adnexal/cervical tenderness and 6 laboratory values such as white blood cell count and ESR can be deranged or normal. One of the major issues of IFTT is its non-specific presentation and its mimicry of conditions such as appendicitis, diverticulitis, bowel obstruction or perforation, ureteric calculi, ectopic pregnancy, ovarian cyst/torsion, Mittelschmerz, and pelvic inflammatory 3-5 disease (PID) among others. Another major issue with IFTT is that only 20% of cases are diagnosed by imaging prior to surgery, meaning that diagnosis is often not made until surgical intervention 4,5. Some authors also describe a chronic/intermittent course to IFTT with repeated bouts of intermittent abdominal pain which resolve spontaneously 1,7. Risk factors for torsion include previous sexually transmitted infection or PID, hydrosalpinx, fallopian tube manipulation, tubal/ovarian or adnexal masses or 1,3,8 neoplasms, adnexal venous congestion, trauma and pregnancy. Further risk factors include anatomical abnormalities, such as mesosalpinx, hypermobile fallopian tubes or 4,5 tubal spasm, and hydatids of Morgani. IFTT is also more common in reproductive aged 5 women. Treatment for IFTT includes laparotomic or laparoscopic detorsion plus salpingotomy, salpingostomy, or salpingectomy depending on when the torsion is discovered, the viability of the tube and whether the patient is systemically compromised. Fixation of the 3,5 tube may also be done to reduce the risk of further torsion events. Pathogenesis for IFTT is thought to be from obstruction of the adnexal veins and lymphatics leading to pelvic congestion and oedema, which causes to fimbrial engorgement 3,9. If left untreated, IFTT leads to ischaemia and necrosis of the tube/ 11 adnexal structures and can ultimately lead to peritonitis and infertility. Torsion can be Page 4 of 14

partial or complete and may or may not comprise vascular flow to the ovary as both structures are supplied by both ovarian and uterine vessels. IFTT occurs more often on the right probably due to the proximity of the left tube to the sigmoid mesentery which may help immobilize the tube and deter against torsion. Another possibility that IFTT is more common on the right side could be the sluggish right sided venous flow compared to the left, which would make congestion more likely on the right. 3,4,10. Images for this section: Page 5 of 14

Fig. 1: Coronal non-contrast CT showing the cystic nature of the mass and its size in relation to the pelvic cavity. Page 6 of 14

Fig. 2: Non-contrast CT image showing the size of the mass in the transverse plane Page 7 of 14

Fig. 3: US image showing the cystic nature of the mass, the relationship between the cyst, bladder and uterus and the lack of an obvious "whirlpool" sign Page 8 of 14

Fig. 4: Contrast enhanced Coronal CT image showing the ongoing cystic nature of the abdominal mass with no obvious change between the initial non-contrast scan Page 9 of 14

Fig. 5: Contrast enhanced CT image showing the cystic mass in the transverse plane Page 10 of 14

Fig. 6: In theatre image showing the torted fallopian tube on delivery outside of the abdomen. Page 11 of 14

Imaging Findings OR Procedure Details 11 The initial imaging modality of choice for IFTT is Ultrasound (US) followed by CT. US findings include a dilated tube with echogenic walls and internal debris; the tube may also present as a twisted cystic/complex or solid mass that can mimic other adnexal or 3,4 ovarian masses and may or may not show abnormal vascular flow. The uterus and ovaries usually appear normal with normal flow although there is often free fluid within the pelvis/abdomen 3,12. CT findings in torsion include a twisted, thickened and dilated (>15 mm) fallopian tube with enhancement and attenuation of the lumen consistent with haemorrhage. Other findings include an adnexal mass, free fluid in the pelvis, a thickened broad ligament and peritubular fat stranding. The uterus may deviate away from the torsion and a regional 3,12 ileus may occur. On CT it can be difficult to distinguish fallopian tube torsion from other pathology like ovarian masses or torsion and patients often need sonography to further differentiate these conditions. MRI has been shown to display similar findings to 11 CT and may be superior for haematoma. Recently some novel imaging signs have been described in the literature which may help improve the diagnosis of torsion and therefore reduce time to surgical intervention and 13 complications. These signs include a "Whirlpool" sign on US and a "Beak" sign on CT. The Whirlpool sign shows as a coiled tortuous mass, which represents a twisted pedicle, detectable on US adjacent to the ipsilateral ovary. This sign was not obvious in the current case but may have more to do with a lack of awareness of the sign/sonographic 1,15 technique than lack of the sign itself. Techniques for optimising US for this sign have 14 been described previously. The beak sign occurs when the vertex of the torted tube tapers off, often towards the adnexa, the direction of the beak may also localize the side of origin for the torsion. On review of the CT images post diagnosis of both the pre and post-contrast films there was no visible beak sign to help diagnose torsion. This may have less to do with the validity of the sign and more to do with the massive size of the 1,3,13 torsion in the current case. Conclusion Isolated Fallopian tube torsion is a rare but important cause of acute abdominal pain in women that is a surgical emergency. Unfortunately due to its rarity, non-specific Page 12 of 14

presentation and the lack of specific diagnostic criteria on medical imaging it is often not diagnosed until surgical exploration. This delay leads to increased morbidity (ischaemia, infertility, perforation etc.) and mortality. Novel findings such as the beak or whirlpool signs as described above may be a helpful in identifying fallopian torsion and avoiding complications of the torsion and unnecessary repeat scans. However, as the current case demonstrates these signs are not always apparent and are not essential in making the diagnosis. In order to prevent the significant side effects of torsion a concerted effort needs to be made to include it as part of our differentials for abdominopelvic pain for women, especially in those women at high risk. This may help reduce time to diagnosis 3 and increase the likelihood of fertility sparring tubal surgery in these women. Hopefully this case report reminds the reader that Isolated fallopian tube torsion (and ovarian torsion in general) is a great mimicker of multiple abdominopelvic pathologies and even though it is a rare condition IFTT deserves to on our differential diagnoses list in reproductive aged women, especially when there are known risk factors present. Personal Information References References: 1) Nakamura Y, Okuda K, Yamashita Y, Terai Y, Yoshida Y and Ohmichi M. Two cases of Isolated Fallopian Tube Torsion diagnosed and treated by laparoscopy: Two different underlying causes. Bulletin of the Osaka Medical College 2011;57:2 2) Bland-Sutton T. Salpingitis and some of its effects. Lancet 1890;2:1146 3) Gross M, Blumstein SL and Chow LC. Isolated Fallopian Tube Torsion: A Rare Twist on a Common Theme. American Journal of Radiology 2005;185:1590-1592 4) Masroor I, Khan J. Torsion of Fallopian Tube, Fimbrial Cyst. J Pak Med Assoc 2008;58:10:571-573 5) Benkaddour Y, Bennani R, Aboulfalah A and Abbassi H. Uncommon Cause of Acute Pelvic Pain: Isolated Torsion of Hydrosalpinx. African Journal of Reproductive Health 2009;13:4:147-150 Page 13 of 14

6) Lineberry T, Rodriguez H. Isolated torsion of the Fallopian tube in an adolescent: a case report. J Pediatr Adolesc Gynecol 2000;13:135-8 7) Phillips K, Elizabeth MF, Kump L, Berkeley A. Chronic isolated fallopian tube torsion: Fertile and Steril 2009;92,394:e1-e3 8) Provost MW. Torsion of the normal fallopian tube. Obstet Gynecol 1972; 39:80-82 9) Bernardus RE, Van der Slikke JW, Roex AJ, Dijkhuizen GH, Stolk JG. Torsion of the fallopian tube: some considerations on its etiology. Obstet Gynecol 1984; 64:675-678 10) Hansen OH. Isolated torsion of the Fallopian tube. Acta Obstet Gynecol Scand 1970; 49:3-6 11) Chiou S, Lev-Toaff AS, Masuda E, Feld RI, Bergin D. Adnexal Torsion: New Clinical and Imaging Observations by Sonography, Computed Tomography, and Magnetic Resonance Imaging; J Ultrasound Med 2007; 26:1289-1301 12) Ghossain MA, Buy JN, Bazot M, et al. CT in adnexal torsion with emphasis on tubal findings: correlation with US. J Comput Assist Tomogr 1994;18:619-625 13) Park BK, Kim CK, Kim B. Isolated tubal torsion; specific signs on preoperative computed tomography and magnetic resonance imaging, Acta Radiol 2008;2;233-5 14) Boopathy VS, Sathiya S. Isolated torsion of the fallopian tube: The sonographic whirlpool sign; J Ultrasound Med 2009;28:657-62 Page 14 of 14