孤立性输卵管扭转:青春期急性盆腔疼痛的罕见病因。

IF 1.6 4区 医学 Q2 PEDIATRICS Journal of paediatrics and child health Pub Date : 2024-07-29 DOI:10.1111/jpc.16629
Khaoula Magdoud, Hiba Mkadmi, Fatma Moussa, Zeineb Ghali, Sana Menjli, Abir Karoui
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The pain has been ongoing for 8 h without radiation to other parts of the body and associated with an episode of vomiting without transit disorder or urinary functional signs. A similar episode that resolved spontaneously 3 months ago was reported. This patient has no medical or surgical history. No abdominal or pelvic trauma was reported. She was a virgin. Menarche occurred at the age of 12 years with irregular cycles. She was on the 25th day of her menstrual cycle.</p><p>On physical examination, the patient was apyretic and haemodynamically stable. Urine Multistix analysis was negative. Abdominal examination revealed a right iliac fossa defence, without palpable mass or abdominal contracture. The lumbar fossa was not tender. The digital rectal examination did not trigger pain. The gynaecological examination was not performed.</p><p>Suprapubic pelvic ultrasound, conducted with a full bladder, showed a normal uterus, and left ovary. The assessment of the right adnexa revealed a unilocular rounded anechoic mass with a regular and thin wall, without vegetation, non-vascularised by colour Doppler, measuring 50 mm in diameter.</p><p>No inflammatory syndrome in biology was found. Serum β-human chorionic gonadotropin (HCG) level was negative.</p><p>The diagnosis of right adnexal torsion was evoked. The patient underwent an emergency laparoscopy.</p><p>On examination, the uterus and left adnexa were normal in appearance. There was a bluish, 5-cm rounded, juxta-uterine mass with fringes, suggesting an isolated torsion of the right fallopian tube, coiling around the utero-ovarian ligament four times in clockwise direction, with ipsilateral unaffected right ovary. No cysts, especially in the mesosalpinx, were found. The appendix was normal (Fig. 1).</p><p>The right fallopian tube was then untwisted. A progressive recoloration was noted after about 10 min of observation and uncoiled tubal recovery was satisfactory (Fig. 2). The right fallopian tube appeared to be abnormally elongated. Conservative treatment with saline solution cleansing and post-operative antibiotic coverage was conducted.</p><p>The post-operative follow-up was uneventful. The patient was fully and clearly informed of her condition. A detailed medical report was delivered.</p><p>The clinical presentation of isolated fallopian tube torsion is misleading, and often misdiagnosed as adnexal torsion.<span><sup>2</sup></span> However, semiology is crucial for the diagnostic orientation towards isolated tubal torsion. The pain usually occurs acutely and is frequently accompanied by one or more episodes of nausea and vomiting.<span><sup>3</sup></span></p><p>It seems that isolated tubal torsion is more common in younger women, especially adolescent girls, compared to adnexal torsion.<span><sup>4</sup></span></p><p>Isolated torsion of the tube does not have pathognomonic symptoms. Acute pelvic pain appears to be the most common clinical presentation.<span><sup>5</sup></span></p><p>Besides, spontaneously resolved ipsilateral iliac fossa pain episode may evoke a previous sub-torsion.</p><p>There are two possible courses of evolution for the pain episode. The first one is subacute type, in which there are some deferred symptoms and thereby delay in the intervention. The other one is acute type, in which there is severe abdominal pain, indicating the need for an emergency surgery.</p><p>Multiple and repeated abdominal palpation to assess the abdominal defence are essential, reflecting the degree of the tube's ischemia, adversely affecting its viability prognosis.</p><p>However, a pelvic mass might be discerned on palpation as well as through pelvic examination.<span><sup>1</sup></span></p><p>In a woman of childbearing age, ectopic pregnancy is systematically considered and typically ruled out using β-HCG assay and pelvic ultrasound.</p><p>The diagnosis of isolated fallopian tube torsion in a young girl is challenging. In this context, it is commonly primordial to rule out acute appendicitis, which is more frequent and consistently considered in the presence of right iliac fossa pain among this population.</p><p>Abdominal, and specifically transvaginal, ultrasound is the gold standard for exploring acute pelvic pain in adolescent girls. It implies locating the ovaries and then looking for a mass, which is most often located between the ovary and the uterine horn. It may sometimes be found in Douglas' cul-de-sac. Initially, the mass is homogeneous and progressively becomes heterogeneous at a more advanced stage, reflecting the presence of areas of haemorrhagic necrosis.<span><sup>6</sup></span> The walls may have thickened due to epithelial oedema.</p><p>In addition, computed tomography and magnetic resonance imaging have not shown their superiority over ultrasound in diagnosis terms.<span><sup>6</sup></span></p><p>Isolated tubal torsion more frequently occurs on the right side. Indeed, the torsion mechanism on the left side is thought to be limited by the presence of the sigmoid colon.<span><sup>7</sup></span></p><p>The underlying mechanisms of isolated fallopian tube torsion are not yet fully understood and seem to be the result of a combination of an anatomical triggering factor and a hemodynamic factor that sustains this process.<span><sup>8</sup></span></p><p>Then there are the hemodynamic factors as follows: The mesosalpinx veins are longer and more flexible than the arteries. When a twist occurs, these veins become congested, facilitating further spiralisation.</p><p>Besides, other aetiologies have been reported in the literature such as tubal hyperperistalsis, tubal sterilisation (especially according to the Pomeroy technique) or abdominal trauma.</p><p>In adolescents, the main risk factors for this condition are mainly congenital hydrosalpinx and sports that involve sudden movements.<span><sup>3</sup></span></p><p>In our observation, the aetiology was most likely excessive length of the mesosalpinx.</p><p>Finally, the treatment of isolated tubal torsion is laparoscopic surgery. It involves untwisting the fallopian tube and assessing its revascularisation after potential warming with saline solution. If revascularisation does not occur, a salpingectomy will be performed.<span><sup>4</sup></span></p><p>Salpingectomy, given the delayed diagnosis, was the most reported treatment in the literature.</p><p>The preservation of the fallopian tube could be discussed even in the case of a persistent necrotic and haemorrhagic appearance.<span><sup>4</sup></span></p><p>The approach to the contralateral adnexa is controversial as bilateral involvement is considered to be rare. In any case, regular monitoring and informing the patient are required.</p><p>Isolated tubal torsion is a rare surgical emergency in adolescent girls. It is underestimated due to the misleading clinical presentation and the non-specificity of imaging tests. The diagnosis should be systematically considered in cases of pelvic pain, as it can impact the fertility prognosis of these young patients. 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引用次数: 0

摘要

6 此外,计算机断层扫描和磁共振成像在诊断方面并未显示出优于超声波。事实上,左侧的扭转机制被认为受到乙状结肠的限制。7 孤立性输卵管扭转的内在机制尚未完全明了,似乎是解剖学触发因素和维持这一过程的血液动力学因素共同作用的结果:中轴静脉比动脉更长、更灵活。此外,文献中还报道了其他病因,如输卵管高蠕动、输卵管绝育(尤其是根据波美技术)或腹部创伤。在青少年中,这种情况的主要危险因素主要是先天性输卵管积水和涉及突然运动的体育运动。在我们的观察中,病因很可能是输卵管系膜过长。最后,孤立性输卵管扭转的治疗方法是腹腔镜手术,包括解开输卵管,用生理盐水加温后评估其血管再通情况。4 由于双侧受累被认为是罕见的,因此对对侧附件的处理方法还存在争议。无论如何,都需要对患者进行定期监测和告知。孤立性输卵管扭转是少女中罕见的外科急症,由于其临床表现具有误导性,且影像学检查没有特异性,因此被低估了。在盆腔疼痛的病例中,应系统地考虑这一诊断,因为它会影响这些年轻患者的生育预后。提高妇科医生对这一病症的了解和认识,可以改善对这些青春期少女的管理。医院中心的伦理委员会认为无需进行伦理审批,因为这是一个在实践中遇到的特殊病例,不涉及任何人体或动物实验。
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Isolated fallopian tube torsion: A rare cause of acute pelvic pain in adolescence

Isolated fallopian tube torsion is a rare surgical emergency in adolescent girls, with an estimated incidence of one in 1 500 000 cases.1 The clinical representation is not specific, leading to challenging and delayed diagnosis, often made intraoperatively. Conservative surgical management is uncommon in these young patients due to late diagnosis.1 This work aims to recall the main characteristics of isolated fallopian tube torsion through a clinical case that successfully underwent conservative treatment.

We report the case of isolated fallopian tube torsion in a 14-year-old girl who consulted the hospital's emergency department due to sudden pain in the right iliac fossa. The pain has been ongoing for 8 h without radiation to other parts of the body and associated with an episode of vomiting without transit disorder or urinary functional signs. A similar episode that resolved spontaneously 3 months ago was reported. This patient has no medical or surgical history. No abdominal or pelvic trauma was reported. She was a virgin. Menarche occurred at the age of 12 years with irregular cycles. She was on the 25th day of her menstrual cycle.

On physical examination, the patient was apyretic and haemodynamically stable. Urine Multistix analysis was negative. Abdominal examination revealed a right iliac fossa defence, without palpable mass or abdominal contracture. The lumbar fossa was not tender. The digital rectal examination did not trigger pain. The gynaecological examination was not performed.

Suprapubic pelvic ultrasound, conducted with a full bladder, showed a normal uterus, and left ovary. The assessment of the right adnexa revealed a unilocular rounded anechoic mass with a regular and thin wall, without vegetation, non-vascularised by colour Doppler, measuring 50 mm in diameter.

No inflammatory syndrome in biology was found. Serum β-human chorionic gonadotropin (HCG) level was negative.

The diagnosis of right adnexal torsion was evoked. The patient underwent an emergency laparoscopy.

On examination, the uterus and left adnexa were normal in appearance. There was a bluish, 5-cm rounded, juxta-uterine mass with fringes, suggesting an isolated torsion of the right fallopian tube, coiling around the utero-ovarian ligament four times in clockwise direction, with ipsilateral unaffected right ovary. No cysts, especially in the mesosalpinx, were found. The appendix was normal (Fig. 1).

The right fallopian tube was then untwisted. A progressive recoloration was noted after about 10 min of observation and uncoiled tubal recovery was satisfactory (Fig. 2). The right fallopian tube appeared to be abnormally elongated. Conservative treatment with saline solution cleansing and post-operative antibiotic coverage was conducted.

The post-operative follow-up was uneventful. The patient was fully and clearly informed of her condition. A detailed medical report was delivered.

The clinical presentation of isolated fallopian tube torsion is misleading, and often misdiagnosed as adnexal torsion.2 However, semiology is crucial for the diagnostic orientation towards isolated tubal torsion. The pain usually occurs acutely and is frequently accompanied by one or more episodes of nausea and vomiting.3

It seems that isolated tubal torsion is more common in younger women, especially adolescent girls, compared to adnexal torsion.4

Isolated torsion of the tube does not have pathognomonic symptoms. Acute pelvic pain appears to be the most common clinical presentation.5

Besides, spontaneously resolved ipsilateral iliac fossa pain episode may evoke a previous sub-torsion.

There are two possible courses of evolution for the pain episode. The first one is subacute type, in which there are some deferred symptoms and thereby delay in the intervention. The other one is acute type, in which there is severe abdominal pain, indicating the need for an emergency surgery.

Multiple and repeated abdominal palpation to assess the abdominal defence are essential, reflecting the degree of the tube's ischemia, adversely affecting its viability prognosis.

However, a pelvic mass might be discerned on palpation as well as through pelvic examination.1

In a woman of childbearing age, ectopic pregnancy is systematically considered and typically ruled out using β-HCG assay and pelvic ultrasound.

The diagnosis of isolated fallopian tube torsion in a young girl is challenging. In this context, it is commonly primordial to rule out acute appendicitis, which is more frequent and consistently considered in the presence of right iliac fossa pain among this population.

Abdominal, and specifically transvaginal, ultrasound is the gold standard for exploring acute pelvic pain in adolescent girls. It implies locating the ovaries and then looking for a mass, which is most often located between the ovary and the uterine horn. It may sometimes be found in Douglas' cul-de-sac. Initially, the mass is homogeneous and progressively becomes heterogeneous at a more advanced stage, reflecting the presence of areas of haemorrhagic necrosis.6 The walls may have thickened due to epithelial oedema.

In addition, computed tomography and magnetic resonance imaging have not shown their superiority over ultrasound in diagnosis terms.6

Isolated tubal torsion more frequently occurs on the right side. Indeed, the torsion mechanism on the left side is thought to be limited by the presence of the sigmoid colon.7

The underlying mechanisms of isolated fallopian tube torsion are not yet fully understood and seem to be the result of a combination of an anatomical triggering factor and a hemodynamic factor that sustains this process.8

Then there are the hemodynamic factors as follows: The mesosalpinx veins are longer and more flexible than the arteries. When a twist occurs, these veins become congested, facilitating further spiralisation.

Besides, other aetiologies have been reported in the literature such as tubal hyperperistalsis, tubal sterilisation (especially according to the Pomeroy technique) or abdominal trauma.

In adolescents, the main risk factors for this condition are mainly congenital hydrosalpinx and sports that involve sudden movements.3

In our observation, the aetiology was most likely excessive length of the mesosalpinx.

Finally, the treatment of isolated tubal torsion is laparoscopic surgery. It involves untwisting the fallopian tube and assessing its revascularisation after potential warming with saline solution. If revascularisation does not occur, a salpingectomy will be performed.4

Salpingectomy, given the delayed diagnosis, was the most reported treatment in the literature.

The preservation of the fallopian tube could be discussed even in the case of a persistent necrotic and haemorrhagic appearance.4

The approach to the contralateral adnexa is controversial as bilateral involvement is considered to be rare. In any case, regular monitoring and informing the patient are required.

Isolated tubal torsion is a rare surgical emergency in adolescent girls. It is underestimated due to the misleading clinical presentation and the non-specificity of imaging tests. The diagnosis should be systematically considered in cases of pelvic pain, as it can impact the fertility prognosis of these young patients. Improving the knowledge and awareness of gynaecologists about this condition can improve the management of these adolescent girls.

Ethical approval is considered unnecessary by the ethics committee of the hospital centre, because this is a unique case encountered during practice and which does not involve any experimentation on humans or animals.

We had written consent from parents for the publication of the article and images.

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来源期刊
CiteScore
2.90
自引率
5.90%
发文量
487
审稿时长
3-6 weeks
期刊介绍: The Journal of Paediatrics and Child Health publishes original research articles of scientific excellence in paediatrics and child health. Research Articles, Case Reports and Letters to the Editor are published, together with invited Reviews, Annotations, Editorial Comments and manuscripts of educational interest.
期刊最新文献
Paediatric oral and maxillofacial biopsies: A retrospective institutional archival study. Letter to the Editor. Long-term outcomes and quality of life in congenital diaphragmatic hernia survivors treated with extracorporeal life support: A cross-sectional survey. Antenatal counselling at the cusp of viability and parental decision-making in the zone of parental discretion: A cohort study. A case of thyroid storm in a child associated with transient central diabetes insipidus.
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