January 1994, Volume 44, Issue 1

Case Reports

Torsion of Pelvic Organs in a 10-Year Old Girl

Nusrat H. Khan  ( Unit I, Department of Obstetrics and Gynaecology, Civil Hospital, Karachi. )

Introduction

Torsion of the normal fallopian tube with or without the ovary is not very rare1. The lesion of the tube preceding torsion is mostly a hydrosalpinx. The interfer­ence in blood- supply converts this to a haematosalpinx1. Primary tumours of the oviduct are seldom diagnosed before operation2. With early diagnosis and treatment it might be possible to conserve normal structures by untwisting the pedicle and resecting the tumours3.

Case Report

A 10-year old Pakistani girl was admitted in emer­gency on July 28th, 1988, with acute abdominal pain and a noticeable swelling in the lower abdomen with the onset of three days. There was no history of onset of menarche. On admission, she was normotensive, tem­perature was 38°C and pulse rate was 92 per minute, regular and of good volume. Abdominal examination confirmed the presence of a mass extending from the symphysis pubis to the umbilicus which was tender on palpation. A provisional diagnosis of twisted ovarian cyst was made. The young girl was anaemic (Hb 10.0g/dl). Mid stream specimen of urine was reported normal. Urgent ultrasound examination was carried out which con­firmed the presence of a solid mass 4.2 cm x 4.2 cm attached to the fundus of the uterus. There was another large cystic mass (8.9 cm x 8.5 cm) attached to the solid mass on the right of the uterus. The provisional ultra­sound diagnosis was: (1) right ovarian cyst, (2) peduncu­lated fibroid. Diagnostic laparotomy was carried out on the same day. Twisted and haemorrhagic right tube-ovarian mass was seen. The right ovary measured 6x3.5x3 cm, filled with chocolate-coloured fluid. The big cyst was at the fimbrial end of the fallopian tube which measured 1 1x9x8 cm filled with watery, brown-coloured fluid (haematosalpinx). There was a small hydrosalpinx on the left side. The left ovary was normal. Right sided salpingo­oophorectomy and left-sided salpingostomy was done. Fluid was aspirated from the left hydro-salpinx and sent for AFB culture. Post-operative period was uneventful. She was discharged home on 8th post-operative day. The histopathology report confirmed haemorrhage (with necrosis) of ovary and fallopian tube; cystadenoma following torsion. Bacteriological examination of the fluid obtained from the right tubo-ovarian mass excluded the presence of mycobacterium.

Discussion

Adnexal torsion is a well-known, poorly recognised and infrequently encountered clinical entity that can involve the tube and ovary, either separately or together2. It is mostly seen in a child or an adolescent due to physiological mobility of organs at these ages1. This was the case in the child. Clinical features are indistinguishable from those caused by tumours of the uterus or ovary2, or of acute appendicitis4. The right adnexa is more frequently involved than the left in torsion by a 3:2 ratio5. If the torsion is suspected or diagnosed, immediate laparotomy is required. If the torsion is incomplete or recent, the tissues may still be viable, it is then possible to conserve them. When the tissues are gangrenous or beyond recovery, they have to be removed1.

References

1. Tindall, V.R., Torsion of pelvic organs, Jeffcoate\\\'s principles of gynaecology, 1987;5:287­-89.
2. Tatum, Hi. Tumours of the oviducts. Current obstetric gynecologic diagnosis and treatmenL 1984;5:30-8.
3. Hibbard, L.T. Adnexal torsion. Am. J. Obstet., Gynecol., 1985;152:456-61.
4. Davis, A.J. and Feins, N.R. Subsequent asynchronous torsion of normal adnexa in children. J.Pediatr., Surg., 1990;25:687-89.
5. James, D.F. Barber, HX and Graber, E.A. Torsion of normal uterine adnexa in children. Report of three cases. Obstet. Gynecol., 1970;35:226-30.
6. Schultz, L.R., Newton, WA. and Clatwottby, H.W. Torsion of previously normal tube and ovary in children. N.Engl.J.Med., 1963;268:343-46.

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