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Ovarian Torsion in a 5-Year Old: A Case Report and Review
http://www.hindawi.com/crim/em/2012/679121/ ( Publisher's URL )
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STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/IR00001315/00001
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Title: Ovarian Torsion in a 5-Year Old: A Case Report and Review
Physical Description: Case report
Creator: Desai, Bobby
Publisher: Hindawi
Place of Publication: USA
Publication Date: 4/22/12
 Notes
Abstract: Ovarian torsion represents a true surgical emergency. Prompt diagnosis is essential to ovarian salvage, and high clinical suspicion is important in this regard. Confounding the diagnosis in general are more commonly encountered abdominal complaints in the Emergency Department (ED) such as constipation, diarrhea, and urinary tract infections and more common surgical emergencies such as appendicitis. Prompt diagnosis can be further complicated in low-risk populations such as young children. Herein, we describe the case of a 5-year-old girl with a seemingly benign presentation of abdominal pain who was diagnosed in the ED and treated for acute ovarian torsion after two prior clinic visits. A brief discussion of evaluation, treatment, and management of ovarian torsion follows.
Acquisition: Collected for University of Florida's Institutional Repository by the UFIR Self-Submittal tool. Submitted by Bobby Desai.
Publication Status: Published
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Source Institution: University of Florida Institutional Repository
Holding Location: University of Florida
Rights Management: All rights reserved by the submitter.
System ID: IR00001315:00001

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H ind a w i P ublishing Co r p o r ation Case R epo r ts in Emergency M edicine V olume 2012, A r ticle ID 679121, 3 pages doi:10.1155/2012/679121 Ca s e R e po r t O v a r ian T orsion in a 5 Y e ar O ld: A Case R e p o r t and R e v i ew M atthew F R yan and B ob b y K. Desai D e pa rt m e nt o f E m er g e ncy M edi c ine, C o ll e g e o f M edi c ine, U niv er si t y o f Flo r ida, P O B o x 100186, Gaines v ille, FL 32610 0186, USA Co r r esponden c e should be add r essed t o B ob b y K. Desai, bdesai@ufl.edu R e c e i v ed 5 M a r c h 2012; A cc ep t ed 22 A p r il 2012 A cademic Edi t ors: V P apa do p oulos and M. Sand Cop y r i g ht 2012 M. F R y an and B K. Desai. This is an o p en a cc ess a r ti c le dis t r ibu t ed under the Cr eat i v e C ommons A t t r ibution Li c ense, w hi c h p e r mits un r es t r ic t ed use, dis t r ibution, and r ep r o duction in a n y medium, p ro v ided the o r i g inal w o r k is p r o perly ci t ed. Ova r ian t orsion r ep r esents a tr ue sur g ical e mergenc y P r o mpt dia g nosis is essential t o o va r ian sa l vage, and hi g h c linical suspicion is impo r tant in this r e ga r d. C onfounding the dia g nosis in gene r al a r e mo r e c o mmonly e n c oun t e r ed ab do minal c omplaints in the Emergency Depa r t ment (ED) su c h as c o nstipation, dia r r hea, and u r ina r y t r act infections and mo r e c o mmon sur g ical e mergencies su c h as appendicitis. P r o mpt dia g nosis can b e fu r ther c o mplica t ed in l o w r isk p o pulations su c h as y oung c hild r en. H e r ein, w e desc r ibe the case o f a 5 y ea r old g irl w ith a seemin g ly beni g n p r esentation o f ab d ominal pain w ho was dia g nosed in the ED and t r ea t ed for acu t e o va r ian t orsion af t e r t w o p r ior c linic v isits. A b r ief discussion of e va l uation, t r ea t ment, and management of o va r ian t orsion fo l l o ws. 1. I n t r o d uc t i o n Ova r ian t o rsi o n can b e an ab do minal catas t r op he f o r w o men, es p ecia l ly if o va r ian sa l vage is not possible. P a thop h ysiological r amifications include o va r ian loss, in t r a abominal infe c tion, sepsis, and e v e n d eath. The ps y c holog ical impa c ts can also be p r ofound [ 1 2 ]. Early dia g nosis and hi g h c linical suspicion a r e k e ys t o p r ompt identification and d efinit i v e s ur g ical t r ea t ment of this dia g nostic dilemma. W e r epo r t on a case o f o va r ian t o rsion in a f i v e y ea r old g irl w ho initia l l y p r esen t ed t o her p edia t r ician w ith nons p ecific ab do minal pain. The r e w e r e s e v e r al fa c t ors that c o nfounded the dia g nosis: firstl y was the fa c t that the patient had b een seen and e xamined t w i c e p r ior t o p r esenting t o the Emergency Depa r t ment (ED). Se c ondl y the mista k e n belief of the r a r i t y of o va r ian t orsion w ithin this patient p o pulation; f i v e y ea r old g irls a r e w e l l w ithin the bimodal dis t r ibution for o va r ian t orsion. A nd lastl y the patien t s seemin g ly beni g n p r esentation. 2. Case R e p o r t A p r e v iously healt h y f i v e y ea r old g irl p r esen t ed t o the ED w ith a o ne d a y his t o r y o f f e v er and r i g ht l o we r q uad r ant pain. She had been e valua t ed b y her p edia t r ician the p r e v ious

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d a y and was dia g nosed w ith acu t e g as t r oen t e r itis af t e r a beni g n p h ysical e xam and ne g at i v e u r inalysis. H o w e v e r her s y mp t o ms p r o g r essed and her pa r ents b r ou g ht her t o an af t e r hours urgent ca r e facili t y w he r e a se c ond u r inalysis was p erfo r med and was a g ain ne g at i v e. The patient was a g ain dis c harged w ith a dia g nosis of g as t r oen t e r itis. The n e xt mo r ning the patien t s pain had be c o me mo r e s e v e r e and she was sent t o the ED b y her p edia t r ician for fu r ther e valuation. U pon p r esentation t o the E D the patient appea r ed i l l and un c omfo r table. She c o mplained o f c onstant pain not r eli e v ed w ith a c etamin o phen or ibup r o fen. H e r r e v iew o f s y mp t o ms was posit i v e for f e v e r one episode o f v omitin g and ab d ominal pain. She was bo r n fu l l t e r m and has a his t o r y o f asthma managed w ith inhaled c o r t i c os t e r o ids and albu t e r ol. She has t w o siblin g s w ho we r e healt h y and she had no i l l c onta c ts. On p h ysical e xam, the patien t s v ital si g ns w e r e w ithin n o r mal pa r am e t e rs f o r h e r age. H e r o r al t e m p e r atu r e was 36.5 C, hea r t r a t e o f 90, blood p r essu r e of 110/70, and r espi r a t o r y r a t e o f 18, and o xygen satu r ation was 100% on r oom ai r The patien t s ab do men was sli g htly dis t e nded and t e nder in the r i g ht l o w er quad r ant, p e l v ic, and s up r apubic a r eas. She had some i n v olunta r y gua r ding but no r ebound t e nde r ness, hepa t osplenome g al y o r c os to v e r t eb r al an g le t e nde r ness. P ain was elici t ed s p ecifica l ly at the r i g ht inguinal

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2 C ase R epo r ts in Emergency M edicine E xplo r a t o r y lapa r os c o p y demons t r a t ed large r i g ht o va r ian cyst (5.5 cm 3.9 cm 3.7 cm) w ith the r i g ht adn e xa t w is t ed 360 The t o rsion was c o r r e c t ed and a r i g ht o va r ian cyst d r ained. The patient was dis c harged o n pos t o p e r at i v e d a y 2 w ithout fu r ther c omplications. F o l l o w up ul t r asound p e r fo r med th r ee months la t er sh o w ed d e v el o ping fo l licles in both adn e xa w ith good a r t e r ial and v enous blood fl o w F igu r e 1: Co mpu t ed t o mo gr ap h y of the p e l v is w ith IV c on t r ast demons t r a t es a c ompl e x locula t ed f l uid c ollection w ithin r i g ht adn e xa. F igu r e 2: Doppler ul t r asound of a large r i g ht o va r ian cyst (estima t ed o va r ian v o l ume o f 41 c m 3 ) d emons t r ating a r t e r ial fl o w but scant v e nous outfl o w li g ament. Classic si g ns for ap p endicitis, including R o vsin g s and P s o as si g ns, we r e absent. The r e mainder of the e xam was no r mal including hea r t t ones, l ung sounds, capi l la r y r efi l l, and skin turgo r H e r cathe t e r i z ed u r ine sample sh o w ed no p r o t ein, k e t o nes, ni t r i t es, or l e u k oc y t e es t e r ase; the mic r os c o pic U A sh o w ed 30 50 r ed blood c e l ls w ith no w hi t e c e l ls o r bac t e r ia. The patien t s w hi t e blood c ount was el e va t ed at 14.6 thou/mm 3 w hile hemo g lobin, hema t oc r it, and pla t elets we r e w ithin no r mal l e v els. A basic c hemis t r y panel was no r mal. C o mpu t ed t o mo gr ap h y (C T ) scan of the ab do men and p e l v is w ith in t r av e nous c o n t r ast demons t r a t ed no r mal solid or g ans and no r mal b o w el g as pat t e r n. A noninflammed ap p e ndix was v isuali z ed. A c ompl e x locula t ed f l uid c o l le ct ion w ithin the r i g ht adn e xa and associa t ed pe l v ic f r ee fluid we r e seen ( Figu r e 1 ). A fo l l o w up ab do minal ul t r asound w ith D o pple r pe r fo r med t o fu r ther in t e r r o g a t e the r i g ht l o w er quad r ant, r e v ealed a si g nificantly enlarged r i g ht o va r y w ith p r ese r v ed a r t e r ial fl o w but scant v e nous outfl o w ( Figu r e 2 ). The left o va r y was n o r mal. 3. Discussion Ova r ian t orsion is a r a r e p r oblem w ithin the p edia t r ic p o p ulation, y e t it r ep r esents a tr ue g yne c olo g ical and sur g ical emergency [ 1 2 ]. Ova r ian t orsion a cc ounts for app r o xi ma t ely 2.7% of a l l cases of acu t e abdominal pain in c hild r e n [ 3 4 ]. A dnexal t orsion is of t e n di cult t o dia g noe g i v e n the p r esen c e of nons p ecific s y mp t o ms and mo r e c ommonly en c oun t e r ed dia g noses. The p r esenta t ion of adnexal t orsion can mimic ap p e ndicitis, u r ina r y t r a c t infe c tion, r enal c olic, g as t r oen t e r itis, or other c onditions of acu t e ab d ominal and p e l v ic pain [ 5 ]. T o rsion o c curs mo r e f r equently in a d oles c ents and y oung w o m e n [ 6 ]. F o r p r e mena r c hal patients, adn e xal t orsion o c curs mostly in neona t es [ 7 ]. H e r e, fetal and ne w bo r n o va r ian cysts d e v el o p d ue t o the hi g h l e v els of ci r culating ma t e r nal ho r mones. The cysts t y pica l ly r eso l v e af t er bi r th w ith w ithd r a wal o f ma t e r nal ho r mones. I n t w o independent sono gr aphic studies, Orsini and c o w o r k ers [ 8 ], and Sala r di et al. [ 9 ] r epo r t ed the t y pical o va r y t o b e solid and homo geneous in e c hogenici t y in p r e mena r c hal g irls less than six y ears o f age. The homogeneous e c hogenici t y is in t e r p r e t ed t o r ep r esent o va r ian pa r e n c h y ma w ithout cysts. La t e r C ohen et al. [ 10 ] sh o w ed mic r ocysts ( < 9 mm in g r ea t est length) t o be c o mmon in g irls 2 12 y ears old but mac r oc y ts t o be less c o mmon, and no cyst was seen in a n y g irl aged 2 12 in their stu d y o f the si z e desc r ibed he r ein. T o rsion o c curs f r equently (60%) o n the r i g ht side p r e sumably b ecause the si g moid c olon le av es limi t ed

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2 C ase R epo r ts in Emergency M edicine E xplo r a t o r y lapa r os c o p y demons t r a t ed large r i g ht o va r ian cyst (5.5 cm 3.9 cm 3.7 cm) w ith the r i g ht adn e xa spa c e for adnexal m o v ement [ 4 11 12 ]. The p r e do minan c e o f r i g ht sided ab d ominal pain c onfounds dia g nosis, and 38% of c hild r en w ith identified adn e xal masses in o ne stu d y we r e initia l l y dia g nosed in the emergency d epa r t ment w ith ap p e ndicitis [ 5 ]. T o rsion is o f t en associa t ed w ith p r e e xisting o va r ian pa tholo g y [ 6 13 ] y et large cysts (as was the case in our patient) a r e thou g ht t o be less li k ely t o undergo t orsion se c o nda r ily t o their si z e and mass [ 14 ]. The large si z e of our patien t s r i g ht o va r y po t entia l ly limi t ed the t o rsion, w hi c h facilita t ed o va r ian sa l vage as the a r t e r ial supply was not y e t c omp r omised. N o r mal p r epu b e r tal o va r ian v olume is app r o xima t ely 1 2 cm 3 [ 15 ]. Our patient had an estima t ed r i g ht o va r ian v o l ume o f 40 c m 3 The dia g nosis of o va r ian t orsion was s uppo r t ed b y ul t r a sound (app r o xima t ely 87% a c cu r a t e for o va r ian patholo g y [ 16 ]). W hile CT m a y be useful in dia g nosing o va r ian t o rsi o n [ 17 18 ], its utili t y he r e was in dis c e r ning ab do minal v e rsus g yne c olo g ical patholo g y for e xample, CT r uled o ut ap p e ndicitis but did not r ule in, satisfa c t o r ily o va r ian t orsion se c o nda r y t o an o va r ian cyst.

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C ase R epo r ts in Emergency M edicine 3 4. Conc l usion [14] B W W a r ne r J C. K uhn, L. L. Ba r r J L. Gr osfeld, R. A. A mou r y and M. W L. Gaude r e r C onse r vat i v e management Pr ompt dia g nosis and e mergent s ur g ical in t e r v e ntion a r e k e ys t o o va r y sa l vage, especia l l y c onside r ing the sensit i v e natu r e of o va r ian loss in the p r epubes c e nt patient. A misdiag nosis can h av e di r e c onsequen c es including o va r ian loss. Our patient was able t o undergo o va r ian sa l vage as blood fl o w was r es t o r ed af t er c o r r ection. M a n y s urgeons r e c ommended a g ainst d e t orsing the o va r y and p r efer o o pho r e c t o m y for c o n c e r ns of embolization [ 18 19 ], y e t no s t r ong e v iden c e e xists t o suppo r t this c laim [ 2 20 22 ]. A s demons t r a t ed in this pape r o va r ian t o rsion can o c cur at a n y age. The r efo r e a hi g h ind e x of suspicion c oupled w ith r adio gr aphic e v iden c e and c linical p r esentation w i l l facilita t e p r ompt dia g n osis and o va r ian sa l vage w ith si g nificantly r edu c ed patient c o mo r b idi t y Publication of this article was funded in part by the University of Florida Open Access Publishing Fund. R efe r e n c es [1] L. L. B r ee c h and P J A. H illa r d, A dn e xal t orsion in pedia t r ic and adoles c ent g irls C u r r e nt O pinion in O bst e tr i c s and G yne c o lo g y v ol. 17, n o 5, p p 483 489, 2005. [2] D A ziz, V D a v is, L. Allen, and J C. Lange r Ova r ian t o rsion in c hild r en: is o op ho r ec t o m y ne c essa r J o u r nal o f P edia tr ic S u r g e r y v ol. 39, n o 5, p p 750 753, 2004. [3] B A. H o e y S. P St a w i c ki, W S. H o R. K. V ee r amasuneni, H. K o v i c h, and M. D Gr ossman, Ova r ian t orsion associa t ed w ith appendicitis in a 5 y ea r old g irl: a case r epo r t and r e v iew of the li t e r atu r e J o u r nal o f P edia tr ic S urg e r y v ol. 40, n o 9, p p E17 E20, 2005. [4] L. T H ibba r d, A dn e xal t orsion A m e r ican J o u r nal o f O bst e t r i c s and G y ne c o lo g y v ol. 152, n o 4, p p 456 461, 1985. [5] A. J P ome r anz and S. Sabnis, M isdia g noses of o va r ian masses in c hild r en and a d oles c ents P edia tr ic E m e rg e ncy Ca r e v ol. 20, n o 3, p p 172 174, 2004. [6] P A. A rgenta, T J Y ea g l e y G. Ott, and S. J Sondheime r T o r sion of the u t e r ine adn e xa: patholo g ic c o r r elations and cu r r ent management t r ends J o u r nal o f R e pr oduc t ive M edi c in e v ol. 45, n o 10, p p 831 836, 2000. [7] P B agolan, C. Giorlandin o A. N ahom et al., The manage ment of fetal o va r ian cysts J o u r nal o f P edia tr ic S urg e r y v ol. 37, n o 1, p p 25 30, 2002. [8] L. F Orsini, S. Sala r di, and G. Pi l u, P e l v ic o rgans in p r eme nar c heal g irls: r eal time ul t r asono gr ap h y Radi o lo g y v ol. 153, n o 1, p p 113 116, 1984. [9] S. Sala r di, L. F Orsini, and E. C a c cia r i, P e l v ic ul t r asonog r a p h y in p r e m e na rc heal g i r ls: r ela t i o n t o pu b e r t y and s ex ho r mone c on c e n t r a t ions A r chives o f D i s ea s e in Childhood v ol. 60, n o 2, p p 120 125, 1985. [10] H. L. C ohen, P E isenber g F M andel, and J O H alle r Ova r ian cysts a r e c ommon in p r e mena r c hal g irls: a sono gr aphic stu d y o f 101 c hild r en 2 12 y ears old A m e r ican J o u r nal o f R o e nt g e n o lo g y v ol. 159, n o 1, p p 89 91, 1992. [11] F Alb a y r am and U M. H am p e r Ova r ian and adn e xal t o rsion: spec tr um of sono gr aphic findin g s w ith patholo g ic c o r r elation J o u r nal o f Ul t r a s o und in M edi c ine v ol. 20, n o 10, p p 1083 1089, 2001. [12] D H. N i c hols and D J J ulina, T o rsion o f the adn e xa Clinical O bs t et r i c s and G y ne c o lo g y v ol. 28, n o 2, p p 375 380, 1985. [13] A. C elik, O E r g u ¨ n, H. Aldemir et al., t e r m r esults of c o nse r vat i v e management of adn e xal t orsion in c hild r en J o u r nal o f P edia tr ic S urg e r y v ol. 40, n o 4, p p 704 708, 2005.

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C ase R epo r ts in Emergency M edicine 3 4. Conc l usion [14] B W W a r ne r J C. K uhn, L. L. Ba r r J L. Gr osfeld, R. A. A mou r y and M. W L. Gaude r e r C onse r vat i v e management of large o va r ian cysts in c hild r en: the va l ue o f se r ial p e l v ic ul t r asonog r ap h y S u r g e r y v ol. 112, n o 4, p p 749 755, 1992. [15] L. Ga r el, J Dubais, A. G r i g non, D Filia t r ault, and G. V an Vliet, o f the pedia t r ic female pe l v is: a c linical perspect i v e Radio g r aphi c s v ol. 21, n o 6, p p 1393 1407, 2001. [16] S. B V ij a y a r a g h a van, Sono gr aphic whirlpool si g n in o va r ian t o rsion J o u r nal o f Ul t r a s o und in M edi c ine v ol. 23, n o 12, p p 1643 1649, 2004. [17] A. M. Gittl e man, A. P P r i c e, L. G o ne r and D S. K atz, Ova r ian t o rsion: CT findin g s in a c hild J o u r nal o f P edia tr ic S u r g e r y v ol. 39, n o 8, p p 1270 1272, 2004. [18] E. R. K o k oska, M. S. K elle r and T R. W ebe r A cu t e o va r ian t o rsion in c hild r en A m e r ican J o u r nal o f S urg e r y v ol. 180, n o 6, p p 462 465, 2000. [19] J M o r d ehai, A. J M a r es, Y B a r ki, R. Final y and I. M eizne r T orsion of u t e r ine adn e xa in neona t es and c hild r en: a r epo r t of 20 cases J o u r nal o f P edia tr ic S urg e r y v ol. 26, n o 10, p p 1195 1199, 1991. [20] J F A nders and E. C. P o w e l l, U rgency of e valuation and o ut c o me of acu t e o va r ian t o rsion in p edia t r ic patients A r c h i ves o f P edia tr i c s and A d o le s c e nt M edi c ine v ol. 159, n o 6, p p 532 535, 2005. [21] S. E. Dol g in, M. L ublin, and E. Shlas ko M aximizing o va r ian sa l vage w hen t r eating idi o pathic adn e xal t orsion J o u r nal o f P edia tr ic S urg e r y v ol. 35, n o 4, p p 624 626, 2000. [22] M. A b e s and H. Sa r ihan, O op ho r o p e xy in c hild r en w ith o var ian t orsion E u ro pean J o u r nal o f P edia tr ic S urg e r y v ol. 14, n o 3, p p 168 171, 2004.