Ultrasound for Ovarian Torsion

A good way of organizing the differential diagnosis for abdominal pain in the pediatric female is by system; for example:

GI: Appendicitis, cholecystitis, gastroenteritis, mesenteric adenitis, small bowel obstruction, intussusception, pancreatitis, colitis.

GU: UTI/cystitis, renal stones.

GYN: Ovarian/adnexal torsion, tubo-ovarian abscess, PID, ovarian cysts, ectopic pregnancy in the sexually active adolescent female, mittelschmerz.

MSK/abdominal wall: Spasm, hematoma, strain

A pelvic ultrasound is key in diagnosing pathology of the adnexa, appendix, and for identifying intussusception. The most important lab test for anyone who even has a chance of being pregnant is a pregnancy test. Other labs that are frequently ordered, although their utility is highly questionable are CBC to identify leukocytosis and inflammatory markers such as CRP. These are, however, non-specific tests.

This patient demonstrated decreased blood flow to the left ovary and was later found in the OR to have a necrotic left ovary which was subsequently removed.

Given this is a surgically managed disease process, our role as emergency physicians is in rapid and accurate diagnosis. Once a likely diagnosis of ovarian torsion is made, emergent GYN consultation should be sought. The patient should be made NPO, IV fluids started, and pain management addressed with pain level frequently reassessed. Pre-operative tests should be sent, and close monitoring for development of shock while the patient is still under our care is key.