management ovarian torsion mekonnengeppt

management of ovarian torsion

1. Case presentation on diagnosis & management of the Ovarian cyst in ovarian Torsion Presenter: Dr Mekonnen G(R-II) Moderator: Dr Seid (R-IV) 1 Z MH/ Aprill , 2023 4/3/2023 By Dr. MEKONNEN G.

2. Outline Objective Case summary Discussion Summary Comments References 2 4/3/2023 By Dr. MEKONNEN G.

3. Objective To discus on diagnosis & management of the Ovarian cyst in ovarian torsion 3 4/3/2023 By Dr. MEKONNEN G.

4. Identification Name: S.N Age: 25 years Phone number : 09******56 MRN: 72***5 Address: AA, Bole,K-5 Date of referral from LHC 17/07/15 E.C Time of arrival at ZMH 8:37pm Evaluation at ZMH EGOPD 17/7/15 E.C at 8:40pm Date of surgery 18/07/15 E.C Date of discharge 20/07/15 E.C 4/3/2023 By Dr. MEKONNEN G. 4

5. Case summary A 25 years old NG lady whose LNMP was 2 weeks back, which she presented with right lower abdominal pain of 6 hrs duration. It is dull aching in type that doesn't shift to elsewhere. Associated to this she has experienced non projectile vomiting of ingested matter of one episode. Otherwise she has no history of: Vaginal bleeding or foul smelling vaginal discharge Fever , chills, or rigor Urinary urgency, frequency or dysuria Diarrhea or constipation Tinnitus, vertigo or easy fatigability Chronic medical illness like DM, HTN, chronic renal disease or CLD 4/3/2023 By Dr. MEKONNEN G. 5

6. Physical Examination General Appearance;- ASL Vitals : BP = 100/70mmHg - PR = 96 RR = 20 - T = 36.7 HEENT : Pink conjunctive, Non – Icteric Sclera LGS;- No LAP Chest;- Clear with good air entry CVS;- S1 and S2 well heard, no murmur and gallop Abd;- Full that moves with respiration There is RLQ deep tenderness No guarding or rigidity No sign of fluid collection GUS;- PV ;- cervix is closed , firm & regular There is RT adnexal tenderness on bimanual palpation IS, MSS---NAD CNS ;- COPPT GCS – 15/15 4/3/2023 By Dr. MEKONNEN G. 6

7. Assessment:- Right ovarian torsion amoebiasis Plan:- Do CBC,BG &RH Prepare at least 2 units of X-matched blood Consult senior (consulted) Prepare for exploratory laparotomy 4/3/2023 By Dr. MEKONNEN G. 7

8. CBC = WBC-13.54k(NE-91.7%, 5.8 %) BG & RH—B positive UAA= normal U/HCG= Negative U/S;- The RT ovary is enlarged measures 7*4.8cm with central septated cystic lesion. There are prominent peripheral follicles and central echogenic stroma at rest of ovarian parenchyma. There is RT pelvic tenderness and decreased flow on color doppler study. Mild pelvic free fluid collection is seen, likely reactive. Swirl pol sign is not demonstrated. conclusion : findings are suggestive for RT acute ovarian torsion(central cystic lesion functioned as lead point) Investigations 4/3/2023 By Dr. MEKONNEN G. 8

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10. Operation note Procedure;- detorsion and cyst aspiration Skin incision ;- pfannenstiel incision IOF;- Intact non gravid uterus Enlarged and edematous RT ovary with cyst measuring 8*7cm in size torsed 360 degree with no color change Health looking epsilateral fallopian tube and contralateral ovary and fallopian tube Done ;- RT ovary was detorsed and about 60cc of serous cystic fluid was aspirated from the cyst Duration;- 45 minutes EBL:- 50ml 4/3/2023 By Dr. MEKONNEN G. 10

11. Follow V/S Q15’ for the 1 st 2hrs, then QID Send post OP CBC after 6 hrs Put on NS/DNS/RL till she start sips Ampicillin 2gm iv qid #03 doses Diclofenac 75 mg im TID Tramadol 50mg iv TID Remove catheter when she starts ambulation Keep dressing for at least 48hrs Metronidazole 500mg PO TID for 10 days Start sips after 02 hrs Encourage early ambulation 11 Plan: 4/3/2023 By Dr. MEKONNEN G.

12. *Post op CBC: Hgb =13g/dl, Hct = 39.6 % Plt =379k 4/3/2023 By Dr. MEKONNEN G. 12

13. Discharged with: Metronidazole 500mg PO TID Appointed to come at GRC after 1 week 4/3/2023 By Dr. MEKONNEN G. 13

14. Problem lists Ovarian cyst with ovarian torsion amoebiasis Question and comments ???? 4/3/2023 By Dr. MEKONNEN G. 14

15. INTRODUCTION O varian torsion is a gynecologic condition that can involve partial or complete rotation of the ovary. It frequently affects the infundibulo pelvic and utero-ovarian ligaments. One of the most frequent gynecologic crises 4/3/2023 By Dr. MEKONNEN G. 15

16. DIAGNOSIS A definitive diagnosis of ovarian torsion is based upon surgical findings. The clinical diagnosis  High index of suspicion! The clinical diagnosis of ovarian torsion should be considered with the triads; lower abdominal pain ovarian cyst/mass diminished or absent blood flow in the ovarian vessels, after exclusion of other causes In our case: Lower abdominal pain Ovarian cyst Diminished blood flow 4/3/2023 By Dr. MEKONNEN G. 16

17. Sonography Ultrasonography is the first‐line diagnostic assessment S onographic findings can vary widely depending on the degree of vascular compromise, the characteristics of any associated intraovarian or intratubal mass, and the presence or absence of adnexal hemorrhage. Sonographically , torsion may mimic ectopic pregnancy, tubo -ovarian abscess , hemorrhagic ovarian cyst, and endometrioma . Accordingly , rates of correct diagnosis range from 50 to 75 percent 4/3/2023 By Dr. MEKONNEN G. 17

18. Sonographic findings Ovarian edema Enlarged ovary (>4cm) Midline ovarian position Variable echogenicity (hypo- or hyperechoic ) Peripherally displaced multiple follicles with hyperechoic central stroma Free Pelvic fluid in >80% of cases An underlying ovarian lesion may be seen (Possible lead point) In our case Enlarged ovary (7*4.8cm) Prominent peripheral follicles with central echogenic stroma Mild pelvic free rluid 4/3/2023 By Dr. MEKONNEN G. 18

19. Sonographic findings cont … Heterogeneously enlarged ovary is the most common ultrasound finding In some cases of torsion, the ovaries continue to have a normal appearance and blood flow. Presence of normal appearing ovaries does not rule out the diagnosis. 4/3/2023 By Dr. MEKONNEN G. 19

20. Doppler Findings Little or no ovarian venous flow (sensitivity-100% & specificity-97%) Absent arterial flow (less common, sign of poor prognosis) Normal vascularity (doesn’t rule out intermittent torsion or dual supply from ovarian and uterine arteries) Tenderness to transducer pressure Bull's-eye target, whirlpool, or snail shell Follicular ring sign In our case Rt pelvic tenderness Decreased flow 4/3/2023 By Dr. MEKONNEN G. 20

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22. Objective : A systematic review and meta-analysis was done to compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT. Ultrasound sensitivity was 79% and specificity was 76%. Doppler ultrasound sensitivity 80% and specificity 88 %. For MRI sensitivity was 81% and specificity was 91%. Conclusions : Ultrasound has good performance as a first-line diagnostic test for suspected AT. MRI could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed. 4/3/2023 By Dr. MEKONNEN G. 22

23. Laboratory tests C BC HCT serum electrolytes Urine HCG Tumor markers In our case Slight leukocytosis with neutrophil predominance 4/3/2023 By Dr. MEKONNEN G. 23

24. Differential diagnosis Ectopic pregnancy Ruptured or hemorrhagic cysts Appendicitis Pelvic inflammatory disease Degenerating leiomyoma Endometriosis 4/3/2023 By Dr. MEKONNEN G. 24

25. MANAGEMENT  Torsion is considered as an emergency The mainstay of treatment is surgery Removal of the affected ovary Conservative surgery Multiple reports over the past 15 years have described Minimally invasive procedures that detorsed and preserved the ovary  return of normal hormonal function and fertility. Ovarian removal  ovarian evaluation and likely preservation, even in the face of a dusky, seemingly necrotic appearance . 4/3/2023 By Dr. MEKONNEN G. 25

26. Management cont.. Premenopausal patients with a viable, nonmalignant ovary: Detorsion Other patients: Salpingo -oophorectomy  Nonviable ovary  Suspicion for malignancy Postmenopausal patients    4/3/2023 By Dr. MEKONNEN G. 26

27. Management cont.. Traditionally, salpingoophorectomy was recommended as the standard treatment for adnexal torsion due to fear of thromboembolism. But now, conservative treatment that consists of untwisting the adnexa followed by cystectomy or cyst aspiration is the management of choice . In our case Detorsion and cyst aspiration done 4/3/2023 By Dr. MEKONNEN G. 27

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29. conclusion E ven necrotic-looking ovaries may benefit from ovary sparing detorsion without oophorectomy. Visual appearance of a necrotic ovary during surgery is not a good predictor of necrosis on subsequent histopathology. While our results suggest that detorsion without oophorectomy could be the mainstay treatment in ovarian torsion Further investigation is required to assess the safety and viability of the ovaries that were preserved following detorsion , and confirm that necrosis did not develop afterwards 4/3/2023 By Dr. MEKONNEN G. 29

30. Conclusion Several articles have previously discussed conservative management of ovarian torsion,. The care of suspected ovarian torsion, which can happen at any age, from prepubertal to postmenopausal, is surgical. According to earlier research, ovarian torsion necessitates oophorectomy because untwisting the ovarian pedicle could result in emboli. Recent research has suggested that detorsion combined with ovarian cystectomy should be the first line of treatment . If a cyst is present, normal ovarian function often follows, even in ovaries that do not first appear to be viable. This management is crucial for young ladies and prepubescent girls. Oophoropexy might be useful for avoiding recurrent torsion. 4/3/2023 By Dr. MEKONNEN G. 30

31. A 10 year old pt presented with RT lower abdominal pain of 1 month duration U/S- enlarged, septated RT ovarian cyst measuring 6.5 cm with echogenic contents Doppler- outer flow with negative core 4/3/2023 By Dr. MEKONNEN G. 31

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34. PREVENTION OF RECURRENCE The role of ovarian suppression with oral contraceptives or oophoropexy for the prevention of recurrent torsion events remains uncertain. 4/3/2023 By Dr. MEKONNEN G. 34

35. summary Ovarian torsion has been attributed to a variety of etiologies: Cysts and neoplasms accounted for 94 percent of cases . Ultrasonography is the first‐line diagnostic assessment The two most common clinical presentations of ovarian torsion are: pelvic pain, which is usually acute and adnexal mass A definitive diagnosis of ovarian torsion is based upon surgical findings. Torsion is considered as an emergency the mainstay of treatment is surgery: removal of the affected ovary or conservative surgery Currently the management of choice for ovarian torsion is conservative treatment that consists of untwisting the adnexa followed by cystectomy or cyst aspiration. 4/3/2023 By Dr. MEKONNEN G. 35

36. comments Referral from health center was appropriate and timely. EGOPD Evaluation was timely (at arrival ). T he diagnosis of amoebiasis is based on??? (result is not available) and the duration of antibiotic is long ( 7 days is enough ). Procedure done is appropriate and timely. No documentation about sending histopathology from aspirated fluid?? Follow up after surgery is not as ordered. No clear documentation about subsequent follow up. 4/3/2023 By Dr. MEKONNEN G. 36

37. References Kariman Ghazal, Charlotte El Hajjar , Zaynab Kalach , Jihad Al Hasan . (2023) Ovarian Torsion no Age Is Exempt Conservative Management Should Always Be the Rule Case Series. J. Women Health Care and Issues. 5(6); DOI:10.31579/2642-9756/134 Yildiz A, Erginel B, Akin M, et al. A retrospective review of the adnexal outcome after detorsion in premenarchal girls. Afr J Paediatr Surg 2014; 11: 304–7. Ibrahim A. Abdelazim,Mohannad AbuFaza , Yerbol Bekmukhambetov , Gulmira Zhurabekova , Svetlana Shikanova , Postmenopausal adnexal torsion: rare case report, Menopause Rev 2020; 19(1): 49-51 Maria Novoa1· Jonathan Friedman2· Maximiliano Mayrink1, Ovarian torsion: can we save the ovary?, Archives of Gynecology and Obstetrics (2021) 304:191–195 Wattar , B., Rimmer , M., Rogozinska , E., Macmillian , M., Khan, K. and Al Wattar , B., 2020. Accuracy of imagingmodalities for adnexal torsion: a systematic review and meta‐analysis Moro F, Bolomini G, Sibal M, Vijayaraghavan SB, Venkatesh P, Nardelli F, Pasciuto T, Mascilini F, Pozzati F,Leone FPG, Josefsson H, Epstein E, Guerriero S, Scambia G, Valentin L, Testa AC.Imaging in gynecologicaldisease (20 ): clinical and ultrasound characteristics of adnexal torsion. Ultrasound Obstet Gynecol. 2020 Dec;56(6 ):934-943 . Marc R Laufer , MD, ovarian and fallopian tube torsion, May 17, 2022 4/3/2023 By Dr. MEKONNEN G. 37

38. Thank you!!! 4/3/2023 By Dr. MEKONNEN G. 38