Author Information
Dixit K*, Setty JP**,
Jassawalla N***, Srikanth ****
(*Third year resident, **
Professor and HOD, ****Second year resident, Department of Radiodiagnosis, *** Third
year resident, Department of Obstetrics and Gynaecology, J.J.M.
Medical College ,
Davanagere, Karnataka , India.
Abstract
Isolated torsion of the
fallopian tube is a rare condition occurring primarily in the reproductive age
group in which patients present with lower abdominal pain. Herein, we report a
case of isolated fallopian tube torsion in a post menopausal woman which was
misdiagnosed on Ultrasonsography (USG) as multilocular ovarian cyst.
Intra-operative findings confirmed fallopian tube torsion.
Introduction
Isolated torsion of the fallopian
tube is a rare entity manifesting as acute abdomen. The incidence is about 1 in
1,500,000 women[1]. Paucity of pathognomonic signs often lead to misdiagnosis.
Case Report
A 55 year old post menopausal
lady presented with acute onset lower abdominal pain since last 4 days with no
other positive symptoms. On examination pulse rate of 106 beats per minute was
noted. Per abdomen mobile mass of 12 to 14 weeks of gravid uterine size was
present over the hypogastric region. On bimanual examination uterine size could
not be made out, bilateral forniceal fullness was present with tenderness in
the right fornix. USG showed a well-defined multilocular complex cystic lesion
in the right adnexa measuring 13x9x7 cm with few incomplete septae and few low
level echoes. Septations appeared thin < 3 mm and showing septal color
uptake with a high resistance flow with RI of > 0.8. Right ovary could not
be visualized separately.
Figure 1. Well encapsulated
pyriform cystic lesion with incomplete septae showing color uptake of high
impedance.
On the left there was well
defined multilocular cystic lesion measuring 7x6 cm with no internal and
peripheral color uptake. These findings suggested the possibility of bilateral
cystadenoma of mucinous variety. Positive whirlpool sign was noted in the right
adnexa with a suspicion of torsion. She had leucocytosis on routine hemogram.
Liver and renal functions tests were normal. CA-125 levels were in the normal
range. Exploratory laparotomy revealed retort shaped gangrenous right hydrosalpinx
of 14x9x8 cm with two rotations at the neck with the normal sized ovary on the
right side and a left ovarian cyst of 8x7x5 cm. Total abdominal hysterectomy
with bilateral salpingo oophorectomy was done. Histopathology confirmed right
gangrenous hydrosalpinx.
Figure 2. Macroscopic appearance
of right gangrenous hydrosalpinx and left ovarian cyst.
Discussion
Isolated torsion of the
fallopian tube is an unusual gynecologic entity manifesting as pain in the hypogastrium
and iliac regions. Various causes of fallopian tube torsion have been
postulated such as anatomical anomalies
(tubal abnormalities such as
hematosalpinx and hydrosalpinx), Physiological
abnormalities such as hyperperistalsis or spasm of the tube, Blood flow dynamic
abnormalities leading to mesosalpingeal venous congestion, Infections like pelvic
inflammatory disease, injuries, and tubal surgeries like tubectomy, pregnancy
(may occur without ipsilateral ovarian involvement), hysterectomy without
salpingo- oophorectomy, endometriosis and tubal malignancy.[1,2]
It is rare before menarche
and during menopause because apparently the risk factors occur mainly during
the reproductive age group. Right sided torsion is commoner than the left. This
is partly due to congestion of the right fallopian tube due to slow venous
drainage or hindered mobility of left tube by the sigmoid colon.[2] Ipsilateral
radiating pain, that begins at the lower abdomen or pelvis but may refer to the
flank or thigh is the most common complaint. Associated symptoms include
retching and vomiting. The differential diagnosis includes torsion ovarian
cyst, acute appendicial etiology, adnexal pregnancy, pelvic inflammatory
disease and degenerating fibroid.[3] Rarely mesenteric panniculitis and
epiploic appendagitis can be a cause of right iliac fossa pain. Imaging
findings in torsion of fallopian tube are imprecise and not specific and
clinical correlation is imperative. USG findings of dilated fallopian tube
(hyperechoic wall, incomplete septae, foci of echogenicity protruding into
lumen, tapering end towards cornua of the uterus, endosalpingeal folds ) with a
normal-appearing ipsilateral ovary are found. Baumgartel et al described the
manifestations of high-resistance flow; although very uncommon or absence of
flow in a tubular structure as sign of tubal torsion.[4] Whirlpool sign on
rocking probe movement is specific.[5] This patient was misdiagnosed as torsion
of the right ovarian mucinous cystadenoma as there was an evidence of mucinous cystadenoma
on the contralateral side. Laparoscopic adnexal detorsion is the treatment of
choice in the child bearing age and complete resection is recommended in
patients with completed family, in the settings of associated neoplasms and when the tube has undergone infarction
and gangrene.[6] In conclusion although fallopian tube torsion is a rare
entity, it should be considered as a differential of acute lower abdominal pain
in all women. The paucity of specific imaging findings generally leads to a
retrospective diagnosis of this condition.
Acknowledgment
Acknowledgment
We acknowledge Dr. Priyanka
References
- Baxi SH, Shah SJ, Trivedi YN,
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Gomathinayagam T. Isolated Fallopian Tube Torsion with Pregnancy. A Case
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- Baumgartel PB, Fleischer AC, Cullinan JA, Bluth RF. Color Doppler sonography of tubal torsion. Ultrasound Obstet Gynecol 1996. May;7(5):367-370
- Vijayaraghavan SB, Senthil S. Isolated Torsion of the Fallopian Tube: The Sonographic Whirlpool sign. J Ultrasound Med 2009; 28: 657–662.
- Bakshi R, Mehta A. Isolated Torsion of the Fallopian Tube with Hydrosalpinx – A Rare Presentation. The Internet J of Gynecology and Obstetrics 2008; 10(2): 1-3.
Dixit K, Setty JP, Jassawalla
N, Srikanth. Torsion Hydrosalpinx – a Diagnostic Puzzle. JPGO 2016. Volume 3
No. 3. Available from: http://www.jpgo.org/2016/02/torsion-of-hydrosalpinx-diagnostic.html