Isolated Fallopian Tube Torsion

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Diagnosis and reasoning

Acute pelvic pain in a woman of childbearing age is an extremely common presentation in the emergency department, with a wide spectrum of differential diagnoses. A careful history and examination are key towards narrowing down the possibilities; the exact location of the pain is perhaps the most important point in this regard. Key causes of acute left lower quadrant pain include gynecological conditions such as ectopic pregnancy, rupture or torsion of an ovarian cyst, rupture of a corpus luteum cyst, adnexal torsion, and pelvic inflammatory disease (PID); as well as surgical conditions such as diverticulitis and ureteric colic. Examination reveals the presence of cervical motion tenderness and a left-sided adnexal mass, suggesting at a gynecological etiology; this helps narrow down the differentials to either ectopic pregnancy, ovarian cyst related disasters, PID (particularly a tubo-ovarian abscess), or adnexal torsion. Note that the history of a recent withdrawal bleed does not necessarily exclude an ectopic pregnancy; however, the negative urine hCG test does make this possibility unlikely. While computerized tomography (CT) is generally considered the first-line imaging study in most individuals with left lower quadrant pain, an ultrasound scan of the abdomen and pelvis is preferred in women of reproductive age; note also that sonography is sensitive for many of the differentials listed above. This reveals an ominous finding: the presence of the 'whirlpool sign' in the proximal left fallopian tube; this is strongly suggestive of tubal torsion. The dilation and absence of flow in the tubal wall lend further credence to this possibility. Note also the presence of a large cystic mass in the left ovary with a fine reticular appearance; this appears to be an unruptured hemorrhagic ovarian cyst, which might very well be the underlying precipitant of the torsion. She needs urgent laparoscopy; this will both help confirm the diagnosis of fallopian tube torsion, while also allowing the operator to detorse the tube; note that the ultimate outcome is directly related to the timeliness of intervention. The ovarian cyst should be resected at the time of laparoscopy so as to prevent future complications; aspiration alone is less effective an associated with a high rate of recurrence. There is no reason to stop the combined oral contraceptive pills; these may even provide some additional benefit, as they have been shown to reduce the incidence of functional ovarian cysts. Doxycycline is indicated in the management of PID and is not required in this patient; note also that antibiotic prophylaxis is not indicated in gynecologic laparoscopic procedures that involve no direct access from the abdominal cavity to the uterine cavity or vagina. In the patient in this case, laparoscopy showed the left fallopian tube to be edematous, dilated and congested, with the fimbrial end appearing blue; it was twisted at the isthmic end. A 6 cm sized hemorrhagic cyst of the left ovary was also identified. Detorsion of the affected tube resulted in the return of vascularity after 15 mins; the ovarian cyst was resected afterwards.


Discussion

Torsion of the Fallopian tube is a rare gynecological condition known to occur in women of reproductive age; the incidence is unclear as no large scale surveys have been carried out; however, several hundreds of cases have been reported since the first such report in 1890. The condition is generally unilateral, with a predilection for the right side; this might be because of the presence of the sigmoid colon on the left side; or due to slow venous flow causing congestion and the greater willingness to explore right abdominal pain for appendicitis. Fallopian tube torsion can be precipitated by both intrinsic and extrinsic causes; important intrinsic causes include congenital abnormalities of the tubes, abnormal tubal peristalsis, hydrosalpinx, hematosalpinx, neoplasms and previous surgery. Known extrinsic causes include neoplasms and adhesions of the neighbouring organs, pregnancy, pelvic congestion, and movement of or trauma to the pelvic organs. The most common presenting symptoms include pain in the lower abdomen which is often cramping in nature, and which may radiate to the groin or thighs; nausea and vomiting; and urinary symptoms such as frequency, urgency and voiding difficulties. A tender adnexal mass may be identified during the pelvic examination, and cervical motion tenderness may also be present; unfortunately, these clinical features are common to many other pelvic pathologies, making tubal torsion extremely easy to miss. Imaging studies may help demonstrate features suggestive of fallopian tube torsion; transvaginal sonography (TVS), computerized tomography (CT) and magnetic resonance imaging (MRI) are the techniques most commonly used in this regard. TVS is generally the initial investigation performed in these patients. The sonographic sign most specific to the condition is the 'whirlpool sign', i.e. the knot of the torsed fallopian tube; however, this is not always visualized. Doppler ultrasonography may demonstrate absence of flow in the affected fallopian tube, or high impedance; unfortunately, even in normal women, it is often difficult to detect vascular flow in the fallopian tubes, reducing the diagnostic value of this finding. Both CT and MRI may also demonstrate features suggestive of torsion; however, similar to ultrasound, they often are of little help in accurately diagnosing the condition. Thus, imaging studies are more of use in ruling out other diagnoses, rather than ruling in tubal torsion. Diagnostic laparoscopy is currently the gold standard for diagnosis of fallopian tube torsion; in patients in whom the condition is suspected, this should not be delayed; note also that this allows therapeutic intervention as well. Laparoscopic detorsion of the tube is the treatment of choice in premenopausal women; timely intervention is often able to restore the blood supply to the ischemic tissues. Note that if the adnexal tissue is gangrenous, if an underlying malignancy is suspected, or if the woman has completed her family, adnexectomy may be considered instead.


Take home messages

  1. Torsion of the fallopian tube is a rare but important cause of acute lower abdominal pain in women of reproductive age.
  2. A high index of suspicion is essential, particularly since there are no clinical features pathognomonic to the condition.
  3. Imaging studies are more useful in ruling out other differential diagnoses than in ruling in tubal torsion; however, where present, the sonographic whirlpool sign is a strong pointer to the condition.
  4. Early laparoscopic detorsion is the diagnostic and therapeutic procedure of choice in premenopausal women.

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