ADNEXAL TORSION CAUSING A LARGE BOWEL OBSTRUCTION
IMAGING FINDINGS: Figure 1. Initial abdominal radiograph demonstrates no concerning abnormalities. Figure 2. Repeat abdominal radiograph 4 days after symptoms began demonstrates dilated loops of bowel in the left upper quadrant with air-fluid levels. CT of the abdomen and pelvis was recommended. Figure 3. Contrast enhanced CT of the abdomen in coronal projection demonstrates diffuse dilated fluid-filled loops of small and large bowel. Within the pelvis, superior to the urinary bladder, there is a large cystic mass in association with a soft tissue structure on the left (yellow arrow). Figures 4 and 5. Contrast enhanced axial (Figure 4) and sagittal (Figure 5) CT images demonstrate suspected transition point in the sigmoid colon (red arrow) in association with a left adnexal soft tissue structure (yellow arrow), thought to reflect the left ovary given proximity to the left gonadal vein (green arrow). Given findings, a pelvic ultrasound was recommended for further evaluation. Figure 6. Left ovary was not visualized on pelvic ultrasound. In the left adnexal region, a unilocular cystic mass with diffuse low-level internal echoes and an echogenic mural nodule (yellow arrow) was noted.
of bowel obstruction due to adnexal torsion were found in the literature: one because of an ovarian cyst in an elderly woman (5) and the other because of ovarian hyperstimulation syndrome in a woman undergoing IVF treatment (2). To the best of our knowledge, this is the first known case of an ovarian tumor with torsion resulting in a large bowel obstruction. Both large bowel obstruction and adnexal torsion are emergencies. Their overlapping clinical features may however delay diagnosis. Acute large bowel obstruction generally presents with abdominal pain, constipation, and abdominal distension (3). Adnexal torsion similarly presents with abdominal pain, often severe and sudden in onset, however symptoms are often prolonged with intermittent pain due to episodic torsion. Associated symptoms include nausea, vomiting, and fever. Leukocytosis is often present in both bowel obstruction and adnexal torsion. In our case, the patient presented 4 days earlier to the ED with similar complaints. Abdominal radiograph at time of initial visit demonstrated nonspecific air-fluid levels within both the small and large intestines. Symptoms may have been due to a transient adnexal torsion and/or related to evolving obstruction of the large bowel from the pelvic mass. On follow-up presentation, imaging studies indicated LBO and adnexal torsion due to a large cystic mass. LBO was suspected on repeat abdominal radiographs which demonstrated dilation of bowel loops and multiple air-fluid levels within the small and large intestines. Abdominal radiography is helpful to exclude complications of LBO including pneumoperitoneum, pneumatosis, and portal venous gas, while CT is used is often used to confirm the diagnosis and investigate the cause and location of the obstruction (3). Although CT may also be used in the diagnosis of adnexal torsion, ultrasound is the initial imaging modality of choice for suspected adnexal torsion and is superior in diagnosis to other imaging modalities including CT and MRI. Imaging findings suggestive of adnexal torsion include unilateral ovarian enlargement, midline position of the affected ovary, surrounding inflammatory change with pelvic free fluid, and deviation of the uterus toward the side of torsion (1). Additional findings include peripherally displaced antral follicles, an enlarged twisted pedicle, central ovarian edema, and a lead mass. Imaging findings of adnexal torsion may also be seen on CT, which can often be the first imaging modality used in diagnosis due to initially low clinical suspicion for adnexal torsion (1). The patient was taken to surgery for an emergent laparotomy and left salpingoophorectomy was performed. Intra-operative findings included adnexal torsion four times about its axis with incorporation of a portion of the colon into the twisted pedicle. The left ovary was black and necrotic, consistent with prolonged devascularization. The bowel was dilated, but otherwise appeared healthy and without injury. Pathology of the ovarian mass indicated serous borderline tumor (SBT), a rare tumor in this patient’s age group and one that is only rarely associated with cases of adnexal torsion (9).
DANIELLE HAIDARI, BS, TAYSON NGUYEN, DO, NEEL GUPTA, MD, SPENCER BARBERA, BA, JEREMY NGUYEN, MD, FACR
HISTORY: 18-year-old otherwise healthy female presented to the emergency department with 6 days of worsening diffuse abdominal pain that became severe the morning of presentation, with 3 days of associated nausea and vomiting. Additionally, patient had no passage of stool or flatus for these 6 days. She previously presented to the ED 4 days earlier complaining of similar, but less severe pain. At that time patient had a negative abdominal X-Ray and was diagnosed with constipation and prescribed stool softeners with no improvement in symptoms. Patient noted slight abdominal distension and bloating over the last several months.
DIFFERENTIAL DIAGNOSIS: 1. Serous Borderline Tumor 2. Serous Ovarian Cystadenoma 3. Ovarian Cystadenocarcinoma 4. Ovarian Teratoma 5. Ovarian Cyst
FINAL DIAGNOSIS: Serous borderline ovarian tumor with adnexal torsion causing a large bowel obstruction DISCUSSION: We present a case of a serous borderline ovarian tumor in an adolescent complicated by adnexal torsion in association with a large bowel obstruction. Large bowel obstruction (LBO) is often due to underlying colonic malignancy (60-80%), followed by volvulus (11-15%) and diverticulitis (4-10%) (3). Extrinsic compression from adjacent mass is an uncommon cause of LBO (3). Large bowel obstruction secondary to adnexal torsion is even far more uncommon. Cases of adnexal torsion resulting in bowel obstruction have been reported in the neonatal period, although only as related to ovarian cysts. In a 2010 literature review of 19 cases of neonatal ovarian cysts resulting in bowel obstruction, 10 cases were due to adhesions of portions of the bowel due to an adjacent necrotic ovary secondary to torsion. Remaining cases of bowel obstruction were secondary to mass effect from a large ovarian cyst (4). Furthermore, only two related adult cases
FIGURE 1: ABDOMINAL RADIOGRAPH
FIGURE 2: ABDOMINAL RADIOGRAPH
FIGURE 3: CONTRAST-ENHANCED CT
FIGURE 4: CONTRAST-ENHANCED AXIAL CT FIGURE 5: CONTRAST-ENHANCED CT
FIGURE 6: PELVIC ULTRASOUND
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J LA MED SOC | VOL 175 | SUMMER 2023
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