Abdominal pain in a posthysterectomy patient

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She did not recall having any fever and had not recently traveled. Her medical history included pelvic/abdominal pain due to adhesions from past surgeries. Her family history was remarkable for ovarian cancer.

Ms. L had had a miscarriage in 1999. It was early in the pregnancy, however, and she did not suffer any sequelae. She became pregnant the following year and delivered a healthy full-term baby by transverse C-section. She had to return to surgery eight hours later, however, for intraoperative hemorrhage and resecuring of bleeding points.

Ms. L had a laparoscopy in 2001 for a “frozen pelvis” secondary to her adhesions. This was only mildly successful, and she again developed abdominal pain. Finally, in March 2002, she had a hysterectomy that spared her ovaries. 

When I first saw Ms. L, she was in moderate pain, pale, and nauseated but in good spirits and in no obvious distress. Physical examination demonstrated clear lung sounds on auscultation; heart sounds were regular with no rubs, murmurs, or gallops. The abdomen was soft with no organomegaly. Throughout the lower quadrants, there was diffuse tenderness, greater on the left than on the right, and radiation on palpation to the patient's left side. There was no back, flank, or costovertebral angle tenderness. Ms. L's pain symptoms were successfully managed with morphine, Toradol (ketorolac), and Phenergan (promethazine).

Because of Ms. L's nausea, left-sided flank/abdominal pain, and inability to have a bowel movement, as well as her history of multiple abdominal surgeries, our initial differential diagnosis included bowel obstruction, kidney stones, pelvic inflammatory disease (PID), diverticulitis, or a soft-tissue injury. 

Abdominal x-rays did not demonstrate acute disease. Left-sided pelvic calcifications were most likely phleboliths. Urinalysis showed 2+ blood, with no evidence of infection or other abnormalities. At this point, I was pretty certain that Ms. L had a kidney stone. When ureteral calculi are suspected on x-ray, a CT scan or IV pyelogram should be performed. 

Due to Ms. L's past medical conditions, an abdominal and pelvic CT scan was ordered. The scan was read  as status posthysterectomy. No evidence of renal stones was found; however, a 6.5-cm mass was visualized in the left pelvis anterior to the left external iliac vessels. At this point, our differential was changed to left ovarian tumor/cancer, left ovarian torsion, tubo-ovarian abscess, mesenteric cyst, or duplication cyst.

Pelvic ultrasound (transabdominal and transvaginal) with color flow Doppler showed a 4.5-cm, round hypoechoic mass in the left lower abdomen, with no or poor blood flow. A torsed left ovary was the most likely culprit. The gynecologic surgeon on call was contacted. On surgical examination, he found extensive adhesions involving the small and large intestines, as well as torsion of the left ovary.

ANALYSIS

Ovarian torsion is a rare but significant cause of acute lower abdominal pain in women. It is also an important and notoriously difficult diagnosis. The fifth most common gynecologic surgical emergency, ovarian torsion accounts for approximately three percent of all emergency gynecologic surgeries. This becomes significant when the top four surgical emergencies (ectopic pregnancy, corpus luteum accident, pelvic infection, and trauma) are ruled out. The average patient is 26 years old, with 70-75 percent of patients being younger than 30 years. However, not all cases occur in young women; it has been reported that 30 percent of patients are postmenopausal.   

Patients typically present with acute lower abdominal pain that localizes to the involved side and radiates to the back, pelvis, and thigh. Pain is usually accompanied by nausea, vomiting, diarrhea, and/or constipation. Common findings on physical examination include a tender mass, mild fever, tachycardia, and decreased bowel sounds.

Ovarian torsion is believed to be due to increased weight and size of the ovary, which alters the anatomy and can cause twisting. This may be the result of a simple ovarian cyst caused by ovulation (which is why the high incidence of torsion occurs in fertile females). Additional causes include congenital malformations and neoplasms.  

Among the differential diagnoses are ovarian tumor, tubal ovarian abscess, appendicitis, ectopic pregnancy, gastroenteritis, PID, ruptured corpus luteum, ureteral calculi, and perforated colonic carcinoma. A pregnancy exam is vital in any patient suspected of having ovarian torsion, due to the high mortality associated with ectopic pregnancy. Other laboratory tests are used to help rule out any coexisting disease. Urinalysis is effective for diagnosing urinary tract infections or hematuria (nonspecific by itself). A complete blood count is nonspecific. Ultrasound with Doppler flow is the diagnostic imaging study of choice because it can depict blood flow within the twisted vascular pedicle. CT can demonstrate a complex mass, as well as other intra-abdominal and pelvic structures. Laparoscopy is used to confirm the diagnosis, as well as in repair of the condition if possible.
   

Ovarian torsion may exist even when pregnancy is found—in fact, approximately 20 percent of cases are in pregnant women. It has also been reported in women who have had a hysterectomy. Salpingo-oophorectomy used to be the treatment of choice and still is if there is any evidence of necrotic tissue found. Recent studies support the concept of simply untwisting the adnexa. 

Prognosis on repair is excellent with early diagnosis and treatment. The biggest omission when treating female patients with abdominal pain is failing to consider it in the differential diagnosis. Of all patients ultimately diagnosed with ovarian torsion, the condition had been suspected in only 35 percent.

In Ms. L's case, lysis of adhesions and repair of the torsion by oophorectomy were accomplished without difficulty. Her hematuria was due to pressure of the enlarged ovary exerted on the ureter and causing irritation. 

We were able to treat Ms. L promptly because we included ovarian torsion in the differential diagnosis and ordered the ultrasound, even though she was postmenopausal. We were quick to diagnose her with a kidney stone and fortunate to have done a CT scan that identified the mass. Had we performed the IV pyelogram and not the CT scan, the correct diagnosis might have been missed. Ms. L is currently recovering at home and is expected to return to work at any time.

Mr. Roscoe is a physician assistant in the emergency department of the Community Hospital of Anderson, Ind.

Read more

Bider D, Mashiach S, Dulitzky M, et al. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 173:363, 1991.

Fleischer AC, Brader KR. Sonographic depiction of ovarian vascularity and flow: current improvements and future applications. J Ultrasound Med 20:241, 2001.

Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 152:456, 1985.

Koonings PP, Grimes DA. Adnexal torsion in postmenopausal women. Obstet Gynecol 73:11, 1989.

Pena JE, Ufberg D, Cooney N, Denis AL. Usefulness of Doppler sonography in the diagnosis of ovarian torsion. Fertil Steril 73:1047, 2000.

Shih S, Vetto JT, Berek JS. Adnexal torsion. An unusual cause of abdominal pain in postmenopausal women. Am Surg 57:327, 1991.

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