Critical Case Conference
Discussion by Annalisa Rudser MD
Ovarian torsion
- Affects females of all ages
- 80% of cases < 50 y/o
- 1% of pediatric and adolescent girls — can be pre-menarchal but rare
- Cysts and neoplasms account for 94% of cases
- Vasculature of ovary undergoes excessive rotation — venous outflow obstructed –> congestion –> tissue edema –> arterial compromise/ischemia/necrosis
Doppler is not diagnostically useful in children — not sensitive or specific for torsion
CT/MRI identifies edema which is suggestive of torsion but not as good as US
Linam LE, Darolia R, Naffaa LN, et al. US findings of adnexal torsion in children and adolescents: size really does matter. Pediatric Radiology, 37(10), 2007, pp. 1013-1019.
- Calculate the adnexal volume by US
- No confirmed cases of ovarian torsion had adnexal volume < 20 mL
- Adnexal ratio = volume of affected (painful) ovary/volume of unaffected ovary
- Adnexal ratio > 15 was seen in 40%, controls 0%
Transvaginal is better than transabdominal but done more in menarchal females who use tampons or who are sexually active
Clinically significant features of pediatric torsion:
Duration of pain > 48 hours
Vomiting
HR > 100 bpm
Sensitivities of adnexal volume and adnexal ratio are low but have very good specificity and NPV
Helpful tips for interviewing adolescents:
HEADS assessment:
- Home environment
- Education
- Activities
- Drugs/alcohol
- Stressful situations
emshorts 