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Diagnostic dilemma of isolated fallopian tube torsion
  1. Michael Gerard Baracy Jr1,
  2. Janie Hu2,
  3. Holly Ouillette1 and
  4. Muhammad Faisal Aslam3
  1. 1Department of Obstetrics and Gynecology, Ascension St John Hospital, Detroit, Michigan, USA
  2. 2School of Medicine, St Georges University, True Blue, Grenada
  3. 3Department of Female Pelvic Medicine and Reconstructive Surgery, Ascension St John Hospital, Detroit, Michigan, USA
  1. Correspondence to Dr Michael Gerard Baracy Jr; Michael.Baracy{at}ascension.org

Abstract

Paratubal cysts are fluid-filled sacs that grow adjacent to the fallopian tube which can rarely result in torsion. Isolated fallopian tube torsion (IFTT) is a gynaecological emergency that warrants urgent laparoscopic detorsion to salvage the affected tube. IFTT has a proclivity to affect adolescents between the ages of 12 and 15 years and is rarely seen in premenarchal or perimenopausal women. Due to a lack of pathognomonical features, IFTT is difficult to diagnose. Adnexal torsion, including IFTT is a surgical diagnosis and no clinical or imaging criteria is sufficient to diagnose IFTT. Urgent laparoscopy and detorsion are required for preservation of the affected fallopian tube. However, given the diagnostic ambiguity, IFTT diagnosis is often delayed. IFTT should be included in the differential diagnoses for adolescent patients with acute abdomen when imaging demonstrates a normal appendix and ovaries. We report a 15-year-old girl with a 4-day history of abdominopelvic pain and bilateral paratubal cysts resulting in right IFTT.

  • obstetrics
  • gynaecology and fertility
  • reproductive medicine
  • general surgery
  • paediatric surgery
  • ultrasonography

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Background

Isolated fallopian tube torsion (IFTT) is a paediatric gynaecological emergency that often presents with non-specific findings. Due to lack of specific findings and the presence of duplex blood flow to the ipsilateral ovary on ultrasound imaging, diagnosis is often delayed. IFTT should be part of the differential diagnosis of any adolescent female presenting with an acute abdomen with non-specific findings. IFTT is a surgical diagnosis and no clinical or imaging criteria is sufficient for diagnosis or ruling out adnexal torsion in adolescents. In this setting, the clinician should have a low threshold for diagnostic laparoscopy as early intervention can result in sparing the fallopian tube, as demonstrated in our case.

Case presentation

A 15-year-old girl with no significant medical history presented to the emergency department at an outside hospital with 4 days of intermittent abdominal pain. Her pain was noted on awakening 4 days prior to presentation and was located in the right lower quadrant of her abdomen. There was no provoking or inciting factors prior to the onset of the patient’s abdominopelvic pain. The pain was intermittent, sharp and stabbing in nature with radiation to her anterior right thigh. The pain was exacerbated by movement and alleviated by lying still. The patient was in the process of relocating from another state and she reported excruciating abdominopelvic pain during the 8-hour commute. The pain was exacerbated with every bump during her car ride. She had a similar episode 1 year prior that resolved without treatment. She denied fevers, chills, nausea, vomiting, dysuria, diarrhoea and constipation. The patient was pre-coitarche and had a levonorgestrel implant in situ.

On presentation, the patient’s vital signs were stable with a blood pressure of 114/77 mm Hg, a pulse of 77, a temperature of 36.6°C and an oxygen saturation of 100% on room air. The patient’s urine beta-human chorionic gonadotropin (ß-hCG) was negative, and a complete blood count (CBC) and basic metabolic profile did not demonstrate any concerning findings. The urinalysis was positive for nitrites, and the patient was treated for a urinary tract infection. A transvaginal ultrasound was obtained at the outside hospital and showed a right adnexal mass measuring 8 cm×7 cm×6 cm with flow to the right ovarian stroma. The left adnexa had a cystic mass measuring 3 cm×2 cm×4 cm without visualised flow secondary to its location (figure 1A,B). Given these findings, the physician at the outside hospital was concerned for ‘torsion’, and the patient was transferred to our hospital for a higher level of care.

Figure 1

(A,B) Transabdominal ultrasound of right adnexa demonstrating a large unilocular cyst. (A) Large right adnexal cyst. (B) Doppler colour flow demonstrating flow to right ovary.

On arrival to our hospital, the patient presented with intermittent flares of pain and baseline pain had slightly improved. She was given intravenous ketorolac for pain control. On examination, the abdomen was soft and non-tender. Laboratory investigations excluded pregnancy with a negative ß-hCG and appendicitis was deemed unlikely given the patient’s lack of leukocytosis on CBC. Furthermore, if patient had appendicitis, this could be diagnosed laparoscopically. Given the lack of sensitivity of clinical and examination findings for adolescent adnexal torsion and ultrasound imaging with adnexal masses, further imaging studies were not obtained. Based on the patient’s presentation, there was concern for ovarian torsion and she was taken to the operating room for a diagnostic laparoscopy.

Investigations

  • ß-hCG—negative (patient had levonorgestrel implant and was not sexually active).

  • Complete blood count and basic metabolic profile were within normal limits

    • White blood cells (WBC)—8.80×109/L.

    • Haemoglobin 124 g/L.

    • Na+ 139 mmol/L, K+ 3.9 mmol/L, Cl 104 mmol/L, HCO3 23 mmol/L, anion gap 12 mmol/L.

  • Urinalysis was positive for nitrites, moderate bacteria and large blood.

  • Transvaginal ultrasound

    • Right adnexal mass measuring 8 cm×7 cm×6 cm with flow to the right ovarian stroma (figure 1A,B).

    • Left cystic mass measuring 3 cm×2 cm×4 cm without visualised flow due to its location.

Differential diagnosis

Differential diagnoses included intermittent ovarian torsion, ruptured ovarian cyst, urinary tract infection, pyelonephritis, appendicitis and pelvic inflammatory disease (PID). Ectopic pregnancy was not suspected based on patient’s account of abstinence and a levonorgestrel implant in situ. PID was also thought to be improbable because the patient denied being sexually active. Ectopic pregnancy was then ruled out based on a negative ß-hCG. Appendicitis was deemed unlikely given lack of leukocytosis. Based on the presentation, intermittent torsion was felt to be the most likely diagnosis. Ruptured ovarian cyst was less likely as no free intraperitoneal fluid was found on ultrasound. Finally, given nitrites and large blood on the patient’s urinalysis, pyelonephritis and nephrolithiasis could not be ruled out. Based on the concern for intermittent ovarian torsion, urgent diagnostic laparoscopy was recommended to the patient.

Treatment

Intraoperative findings included a large right paratubal cyst approximately 8 cm in diameter and discretely separated from the ovary. The right fallopian tube and cyst appeared dusky and cyanotic, shortened and twisted on itself multiple times confirming fallopian tube torsion (figure 2). The right infundibulopelvic ligament and ovary appeared structurally normal. The left fallopian tube also had a paratubal cyst that measured 4 cm in diameter. Intra-abdominal survey demonstrated a normal appearing appendix, bowel and liver, ruling out coexisting appendicitis or other abdominal pathology. The right fallopian tube was detorted with atraumatic graspers, and the paratubal cyst was found to have rotated six times around the fallopian tube axis. On detorsion, the fallopian tube regained its natural hue with a glistening smooth outer surface (figure 3). An incision was made along the capsule of the paratubal cyst, and the cyst was enucleated using a combination of sharp and blunt dissection (figure 4). In a similar manner, the left paratubal cyst was shelled out. Cautery was used sparingly only on vascular areas. The majority of the process was completed via blunt dissection. Final inspection revealed hemostatic fallopian tubes and normal appearing ovaries. The paratubal cysts were sent to pathology and were subsequently found to be benign.

Figure 2

Right fallopian tube with isolated torsion.

Figure 3

Right fallopian tube and cyst following detorsion.

Figure 4

Decapsulation of right paratubal cyst. An incision was made along the capsule of the paratubal cyst, and the cyst was shelled out using a combination of sharp and blunt dissection.

Outcome and follow-up

The patient had an uneventful postoperative course. The patient followed-up in the clinic 4 weeks postoperatively was doing well and had not experienced any further abdominal pain.

Discussion

Paratubal cysts are hormone-sensitive, fluid-filled sacs lined by a single layer of ciliated cuboidal cells that arise from Mullerian or Wolffian remnants.1 The incidence of paratubal cysts have been reported to be 4% in adolescent girls. They are typically found in proximity to the ipsilateral ovary.2 The majority of paratubal cysts are between 2 mm and 20 mm in size, arise from the peritoneum, and are benign.3 Consequently, most paratubal cysts are asymptomatic and are found incidentally during pelvic surgery. Giant cysts as large as 25 cm have been reported in the literature and are a rare cause abdominoelvic pain secondary to haemorrhage, rupture or torsion.4

Paratubal cysts account for 10% of reported ovarian masses and are the second most common cause of tubal torsion behind ovarian cysts.4–6 Isolated fallopian tube torsion (IFTT) occurs when the fallopian tube undergoes torsion without concomitant ovarian torsion.7 The most common presentation is unilateral lower abdominal or flank pain with tenderness on palpation. Peritoneal signs and occasionally a palpable mass may be present.7 Imaging and laboratory values tend to be non-specific and non-diagnostic. Due to a lack of pathognomonical features, the diagnosis of IFTT is often delayed or missed entirely.8 Diagnostic delay can result in progressive necrosis with the need for subsequent resection of the affected fallopian tube. Because imaging and laboratory values are often non-specific, diagnosis should be confirmed by emergent diagnostic laparoscopy.9 IFTT should be considered in the differential diagnosis of adnexal pain, especially if an adnexal cyst is seen on imaging. Given that other abdominopelvic pathology can be diagnosed during diagnostic laparoscopy, surgery should not be delayed for further imaging studies, especially in an adolescent female. Prompt laparoscopy with detorsion should be considered in an effort to preserve the affected fallopian tube and minimise impact on future fertility.

Although the precise mechanism of IFTT is unknown, the proposed mechanism is that the weight of a giant paratubal cyst results in mechanical rotation of the cyst around the fallopian tube axis.10 IFTT nearly exclusively occurs in adolescents between the ages of 12 and 15 years and is rarely seen in premenarchal or perimenopausal women.7 IFTT is more commonly found on the right owing to the cushioning effect of the sigmoid colon on the left,9 and the tendency to surgically explore the right side to exclude appendicitis.11

Balasubramaniam et al found that lower abdominal pain was the most common presenting symptom in IFTT (88%), with half of patients experiencing radiation to the flanks. Patients also experienced nausea and vomiting (47%), dysuria (17.6%) and diarrhoea (11.7%).10 Due to overlapping clinical features and a paucity of reported cases, IFTT is diagnostically challenging to differentiate from other causes of abdominal pain such as appendicitis, ovarian torsion, ectopic pregnancy and PID.10 As a result, despite being a gynaecological emergency, IFTT is often miss diagnosed and proper management is delayed.

Ultrasound is typically the first imaging modality used in the evaluation of acute abdominopelvic pain. Ultrasound findings that suggest IFTT include a fallopian tube with thick echogenic walls, internal debris and a narrowed end, also known as the beak sign. Additionally, the twisted vasculature may present as a whirlpool sign on ultrasound.12 Colour Doppler can also be used to detect a reduced flow in a torted tube. Lastly, CT findings that are consistent with IFTT include a fallopian tube dilated more than 15 mm, enhancement of the tubal wall and intraluminal attenuation due to haemorrhage.7

Although imaging may be helpful to rule out other diagnoses, the gold standard for definitive diagnosis is laparoscopy. Laparoscopic exploration allows for visual confirmation of IFTT and ruling out other causes. The treatment of IFTT includes detorsion of the affected tube and puncture and drainage or excision of the cyst. Urgent laparoscopy is required to prevent fallopian tube necrosis. When evidence of necrosis or haemorrhage is present, salpingectomy or salpingostomy are often required, however every effort should be made to conserve the fallopian tube.7 Unfortunately, in the majority of cases (82.3%), surgical intervention is delayed, resulting in salpingectomy. Detorsion and conservation of the fallopian tube is only successful in a one in five cases.9

Conclusion

IFTT is a rare clinical entity that is easily misdiagnosed due to the lack of distinguishing clinical features and the wide range of differential diagnoses. Intervention is often delayed due to diagnostic challenges, thereby reducing chances for tubal preservation. In order to preserve future fertility, physicians should have a low threshold for urgent diagnostic laparoscopy for acute onset pelvic pain in an adolescent female in the absence of other pathological, radiographical or laboratory findings.

Learning points

  • Isolated fallopian tube torsion presents in adolescents as acute abdomen or intermittent abdominopelvic pain.

  • Isolated fallopian tube torsion is a gynaecological emergency.

  • Diagnosis of isolated fallopian tube torsion is often delayed secondary to lack of defining clinical features and diagnostic ambiguity.

  • Delay in diagnosis often results in salpingectomy, which can affect future fertility. Given the importance of ovarian preservation, diagnostic laparoscopy should not be delayed for further imaging.

  • The clinician should have a low threshold for diagnostic laparoscopy in adolescent patients who present with acute abdominopelvic pain in the absence of pathological, radiographical or laboratory findings. A negative finding at laparoscopy is an acceptable clinical outcome and should not deter clinicians from surgical management of acute abdomen.

Ethics statements

References

Footnotes

  • Contributors MGB Jr and JH wrote the manuscript. HO contributed to the content of the manuscript and was integral in the editing of the manuscript. MFA was chief editor of the transcript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.