You’re busy at work in the ED of Seattle Grace Hospital when the infamous Dr. Christina Yang (one of the premier cardiothoracic surgeons in your prestigious fictional hospital) makes her way down to the ER after finishing a case in the OR. She tell you that she’s been having severe right-sided pelvic pain all day but wanted to finish her ground-breaking quintuple bypass surgery first. She’s UCG negative and tells you “Of course I am, that’s why I’ve been freezing my eggs, so I can continue my rockstar single life and my stellar career before thinking about having any snot-nosed kids.”
OK… the differential can be wide here, but she tells you she’s done 782 appendectomies and knows her appendix is fine (and you believe her, because she is Dr. Yang), and that she’s been celibate this season of Grey’s Anatomy so it can’t be STD-related. So now what’s high on your differential…?
What are the risk factors for ovarian torsion?Ovarian cysts, PCOS, fertility treatments, tumors and pregnancy. Ovarian cysts are considered large and at increased risk for torsion when they are > 3cm. Any condition that makes your ovary larger puts it at risk for torsion
How does badness from torsion occur?
The ovary twists on it’s vascular pedicle leading to vascular congestion, edema, and ischemia/necrosis. This may involve the ovary alone or the entire adnexa including oviduct.
Classical presentation... not so classical?
We always talk about the classical presentation of sudden onset, 10/10, unilateral pelvic pain (which may certainly occur), but more often in practice the presentation is atypical. This may mean bilateral pain, not severe, non-tender, etc. So have a high degree of suspicion to get that ultrasound and GYN consult. 50% of torsion is initially misdiagnosed! Although ultrasound is often the first line to diagnosis, laparoscopy is the gold-standard as ultrasound can miss torsion.
References
Tintinalli’s 7th ed. Lukens TW, Ch 100.
HippoEM Board Review
Special thanks to Dr Willis, and to Grey’s Anatomy for always glorifying our profession
Kylie Birnbaum
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1 Comment
iandesouza · December 29, 2015 at 6:29 pm
Nice post Birnbaum! I think ALL young women with lower abdominal pain should undergo a pelvic US as the initial diagnostic test. This may eliminate the risk of radiating those valuable eggs when CT becomes unnecessary to make the diagnosis, and in many cases US will confirm the diagnosis. Even a bedside transabdominal US may be sufficient as it is fairly easy to see an ovarian cyst of significant size. If you do, you can go forward with your emergent gyn consultation and “official” US.
What are the most common SIGNIFICANT diagnoses in these patients? IUP, ovarian cyst, salpingitis/TOA, leimyoma, renal colic. Who manages these patients and which imaging do they know? Ob/Gyn and ultrasonography. Doing a CT first in the young female patient should considered an M/M and really grinds my gears.