Question

Difficulty: HardInterpreting Imaging Results

An otherwise healthy 3434-year-old woman is brought to the emergency department due to the sudden onset of severe, right-sided pelvic pain that began abruptly while she was exercising 33 hours ago. She reports two episodes of non-bilious emesis since the pain started. Her last menstrual period was 22 weeks ago, and she has regular 2828-day cycles. She has no history of sexually transmitted infections or prior abdominal surgeries. Her temperature is 37.1∘C37.1^\circ\text{C} (98.8∘F98.8^\circ\text{F}), blood pressure is 132/82 mm Hg132/82\text{ mm Hg}, pulse is 108/min108/\text{min}, and respiratory rate is 16/min16/\text{min}. Physical examination reveals a non-distended abdomen with marked tenderness to palpation in the right lower quadrant. Voluntary guarding is present, but there is no rebound tenderness. Pelvic examination demonstrates a tender fullness in the right adnexa. A urine pregnancy test is negative. Laboratory studies show a leukocyte count of 11,500/μL11,500/\mu\text{L}. A transvaginal ultrasound with color Doppler is performed. The right ovary measures 6.5 cm×5.0 cm×4.5 cm6.5\text{ cm} \times 5.0\text{ cm} \times 4.5\text{ cm} and exhibits a heterogeneous stroma with multiple peripherally displaced follicles. Color Doppler evaluation demonstrates the presence of arterial blood flow, but venous flow is entirely absent. The left ovary is normal in size and appearance. A small volume of anechoic free fluid is noted in the rectouterine pouch (cul-de-sac). Based on the imaging findings, which of the following is the most appropriate next step in management?

  1. Diagnostic laparoscopyAnswer
  2. B
    Discharge home with oral analgesics and outpatient follow-up
  3. C
    Computed tomography of the abdomen and pelvis with intravenous contrast
  4. D
    Initiation of broad-spectrum intravenous antibiotics for presumed pelvic inflammatory disease
  5. E
    Repeat transvaginal ultrasonography with Doppler in 24 hours

Answer

Diagnostic laparoscopy
Diagnostic laparoscopy is the definitive evaluation and treatment for suspected ovarian torsion. The ultrasound findings in this patient—an enlarged, edematous ovary with peripherally displaced follicles (the 'string of pearls' sign) and absent venous flow—are highly specific for early torsion. Because venous pressure is lower than arterial pressure, the twisting of the infundibulopelvic ligament initially occludes venous and lymphatic outflow, leading to severe ovarian engorgement and pain. Arterial inflow often persists in the early stages; therefore, the presence of arterial Doppler flow does not rule out the diagnosis. Prompt surgical intervention is necessary to detorse the ovary and prevent irreversible tissue necrosis.

Step-by-Step Solution

1
Interpret the transvaginal ultrasound imaging findings.
The right ovary is significantly enlarged (6.5 cm6.5\text{ cm}) with peripherally displaced follicles and absent venous flow.
These are the classic morphologic and hemodynamic hallmarks of ovarian torsion.
2
Analyze the significance of the Doppler arterial flow status.
Arterial flow is still present, but this does not safely exclude the diagnosis of torsion.
In early ovarian torsion, the thin-walled, low-pressure venous and lymphatic outflow tracts are compressed first, causing edema. The thick-walled, high-pressure arterial inflow can initially remain intact.
3
Determine the appropriate clinical management based on the imaging interpretation.
Immediate diagnostic laparoscopy is indicated.
Ovarian torsion is a time-sensitive ischemic emergency that requires prompt surgical detorsion to preserve ovarian viability.

Key Concept

In suspected ovarian torsion, an enlarged, edematous ovary with absent venous flow is highly diagnostic; the presence of arterial Doppler flow does not exclude the diagnosis because low-pressure venous and lymphatic compression precedes high-pressure arterial compromise.
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