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Isolated torsion of fallopian tube in a post-menopausal patient: A case report
Maturitas 57 (2007) 325–327
Short communication
Isolated torsion of fallopian tube in a post-menopausal patient: A case report Mahmut Tuncay Ozgun ∗ , Cem Batukan, Cagdas Turkyilmaz, Ibrahim Serdar Serin Erciyes University, Faculty of Medicine, Department of Obstetrics and Gynecology, Kayseri, Turkey Received 7 October 2006; received in revised form 4 January 2007; accepted 8 January 2007
Abstract Isolated fallopian tube torsion after menopause is a rare condition. Here we report the second case of isolated fallopian tube torsion in a post-menopausal woman. A 55-year-old post-menopausal woman presented with right lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the right uterine border. Laparatomy revealed torsion of the right fallopian tube together with a paraovarian cyst. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathological examination revealed a simple paraovarian cyst with severe congestion, necrosis and hemorrhage. Tubal torsion should be considered in the differential diagnosis of acute lower abdominal pain, even in post-menopausal women. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Fallopian tube; Torsion; Postmenopause
1. Introduction Isolated torsion of the fallopian tube is an extremely uncommon cause of acute lower abdominal pain. As clinical findings on physical examination as well as imaging and laboratory characteristics are nonspecific, the condition is almost always diagnosed at the time of surgery [1]. Although isolated torsion of the fallopian tube can occur spontaneously at grossly normal appearing fal∗ Corresponding author at: Erciyes University, Faculty of Medicine, Department of Obstetrics and Gynecology, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. Tel.: +90 533 655 20 14; fax: +90 352 437 76 14. E-mail addresses: [email protected], [email protected] (M.T. Ozgun).
lopian tubes, an underlying predisposing factor, mostly being a tubal and ovarian pathology, is usually present [2]. As these risk factors are more common in the reproductive age, isolated fallopian tube torsion is more frequent during this period and is extremely rare in post-menopausal women. To the best of our knowledge only one such a case has been reported so far [3]. Here we provide a case with isolated torsion of the fallopian tube in a post-menopausal patient.
2. Case A 55-year-old multipara woman, taking no hormone replacement therapy, who had her last menstrual period 5 years ago, was admitted to our clinic because of
0378-5122/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2007.01.006
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M.T. Ozgun et al. / Maturitas 57 (2007) 325–327
imen showed a simple paraovarian cyst. There was severe congestion, necrosis and hemorrhage within the wall of the tube and cyst.
3. Discussion
Fig. 1. Intra-operative appearance of the twisted fallopian tube, showing necrosis and congestion. Note that the ovary (asterisk) and uterus (ut) is totally normal in appearance and a paraovarian cyst is also apparent (arrow).
sudden, right-sided, lower abdominal pain. Her medical history was unremarkable. Physical examination revealed right adnexal tenderness. Ultrasound scan depicted a right-sided, well-circumscribed, purely cystic mass measuring 6 × 6 cm in diameter. There was minimal free fluid in the abdomen. The left ovary and uterus appeared normal on vaginal ultrasonography, but the right ovary could not be visualized. Routine serum biochemistry, hematological evaluation, and tumor markers were all within normal limits. The white blood count was 12,000 mL−1 and axillar temperature was 37 ◦ C. The patient described a similar but less intense pain, which was intermittent in nature, during the last 4 months. During follow-up, as her clinical condition worsened and abdominal guarding and rebound tenderness over a restricted area in the right lower abdominal region developed, laparatomy for a suspected ovarian torsion was performed. At surgery, the right fallopian tube with a paraovarian cyst, twisted two times around its vascular stalk, appeared necrotic and gangrenous. The right ovary was not involved in the pathological process and appeared normal on inspection (Fig. 1). The left tube and ovary, appendix, and uterus were normal. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. The postoperative course was uneventful and the patient was discharged 4 days after surgery. Histopathological examination of the spec-
With an estimated annual incidence of 1 in 1.5 million women, isolated fallopian tube torsion represents an uncommon pathology in the reproductive age [4]. However, its true incidence after menopause has not been established yet. We are aware of only one reported case of isolated fallopian tube torsion after menopause in the English speaking literature [3]. In most of the reported cases of isolated fallopian tube torsion, the right side is more often affected than the left [5]. This could be due to the fact that the mass effect of the sigmoid colon, which is located in the left lower abdomen, might prevent the left tube from twisting around its pedicle. However, the mechanism that leads to isolated fallopian tube torsion is still uncertain. Various suggested theories include anatomic malformations, such as a long mesosalpinx and hydrosalpinx; abnormalities of adjacent organs, such as ovarian and paraovarian masses, uterine enlargement due to pregnancy or tumor, and peri-tubal adhesions; physiologic disturbances in the normal peristaltism of the fallopian tube; hemodynamic alterations causing congestion of the mesosalpingeal veins, as well as previous tubal ligation, trauma or sudden change in body position [6]. The paraovarian cyst may have contributed to the torsion of the fallopian tube in the present case. In most of the cases the presenting symptom is sudden severe lower abdominal pain, which is often accompanied by nausea and vomiting and is located in lower abdomen of the affected side but may radiate to the ipsilateral flank or thigh. As in our patient, in advanced cases peritoneal irritation, with guarding and rebound tenderness may be present, but body temperature, white blood cell count and sedimentation rate are usually within normal range or slightly elevated. As these clinical, laboratory and physical examination findings are non-specific, acute appendicitis, ectopic pregnancy, pelvic inflammatory disease, ovarian torsion, ovarian cyst rupture, intestinal obstruction or perforation, urolithiasis, cystitis, and degeneration of a leiomyoma should be considered in the differential diagnosis of isolated fallopian tube torsion [7].
M.T. Ozgun et al. / Maturitas 57 (2007) 325–327
Isolated tubal torsion should be considered in the differential diagnosis when a patient complaints about severe lower abdominal pain together with a cystic adnexal mass and normal appearing ovaries on ultrasonography. Conservative treatment is possible when definitive diagnosis can be reached before tissue necrosis occurs. This is especially important in younger women, who wish to preserve their further fertility. However, pre-operative diagnosis of isolated tubal torsion is very difficult and the diagnosis usually made during surgical exploration [1]. The management of isolated fallopian tube torsion is surgical, either via laparatomy or laparoscopy. The choice of treatment depends on appearance of the tube in the operation, the patient’s age and reproductive capacity. Due to the pre-operative diagnosis of a suspected ovarian cyst torsion, which might be a malignant process, especially in post-menopausal women, we preferred laparatomy instead of laparoscopy as primary surgical intervention. As many cases are diagnosed beyond the point where a conservative approach might be possible, treatment consists mainly of salpingectomy [8]. Although patients may benefit from simple untwisting of the fallopian tube if there is no apparent ischemic damage [9], the necrotic appearance of the fallopian tube precluded a conservative approach in our case.
327
In conclusion, although it is a rare entity, isolated fallopian tube torsion should be considered in the differential diagnosis of acute lower abdominal pain of post-menopausal women. References [1] Blair CR. Torsion of the fallopian tube. Surg Gynecol Obstet 1962;114:727–30. [2] Filtenborg TA, Hertz JB. Torsion of the fallopian tube. Europ J Obstet Gynec Reprod Biol 1981;12:177–81. [3] Powell JL, Foley GP, Llorens AS. Torsion of the fallopian tube in postmenopausal women. Am J Obstet Gynecol 1972;8: 113–5. [4] Hansen OH. Isolated torsion of the fallopian tube. Acta Obstet Gynecol 1970;49:3–6. [5] Batukan C, Ozgun MT, Turkyilmaz C, Tayyar M. Isolated torsion of the fallopian tube during pregnancy: a case report. J Reprod Med 2007; in press. [6] Bernardus RE, van der Slikke JW, Roex AJM, Dijkhuizen GH, Stolk JG. Torsion of the fallopian tube: some considerations on its etiology. Obstet Gynecol 1984;64:675–7. [7] Ferrera PC, Kass LE, Verdile VP. Torsion of the fallopian tube. Am J Emerg Med 1995;13:312–4. [8] Gross M, Blumstein SL, Chow LC. Isolated fallopian tube torsion: a rare twist on a common theme. AJR Am J Roentgenol 2005;185:1590–2. [9] Raziel A, Mordechai E, Friedler S, Schachter M, Pansky M, RonEl R. Isolated recurrent torsion of the fallopian tube: case report. Hum Reprod 1999;14:3000–1.
Short communication
Isolated torsion of fallopian tube in a post-menopausal patient: A case report Mahmut Tuncay Ozgun ∗ , Cem Batukan, Cagdas Turkyilmaz, Ibrahim Serdar Serin Erciyes University, Faculty of Medicine, Department of Obstetrics and Gynecology, Kayseri, Turkey Received 7 October 2006; received in revised form 4 January 2007; accepted 8 January 2007
Abstract Isolated fallopian tube torsion after menopause is a rare condition. Here we report the second case of isolated fallopian tube torsion in a post-menopausal woman. A 55-year-old post-menopausal woman presented with right lower abdominal pain. Sonography depicted a simple cystic mass adjacent to the right uterine border. Laparatomy revealed torsion of the right fallopian tube together with a paraovarian cyst. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathological examination revealed a simple paraovarian cyst with severe congestion, necrosis and hemorrhage. Tubal torsion should be considered in the differential diagnosis of acute lower abdominal pain, even in post-menopausal women. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Fallopian tube; Torsion; Postmenopause
1. Introduction Isolated torsion of the fallopian tube is an extremely uncommon cause of acute lower abdominal pain. As clinical findings on physical examination as well as imaging and laboratory characteristics are nonspecific, the condition is almost always diagnosed at the time of surgery [1]. Although isolated torsion of the fallopian tube can occur spontaneously at grossly normal appearing fal∗ Corresponding author at: Erciyes University, Faculty of Medicine, Department of Obstetrics and Gynecology, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. Tel.: +90 533 655 20 14; fax: +90 352 437 76 14. E-mail addresses: [email protected], [email protected] (M.T. Ozgun).
lopian tubes, an underlying predisposing factor, mostly being a tubal and ovarian pathology, is usually present [2]. As these risk factors are more common in the reproductive age, isolated fallopian tube torsion is more frequent during this period and is extremely rare in post-menopausal women. To the best of our knowledge only one such a case has been reported so far [3]. Here we provide a case with isolated torsion of the fallopian tube in a post-menopausal patient.
2. Case A 55-year-old multipara woman, taking no hormone replacement therapy, who had her last menstrual period 5 years ago, was admitted to our clinic because of
0378-5122/$ – see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2007.01.006
326
M.T. Ozgun et al. / Maturitas 57 (2007) 325–327
imen showed a simple paraovarian cyst. There was severe congestion, necrosis and hemorrhage within the wall of the tube and cyst.
3. Discussion
Fig. 1. Intra-operative appearance of the twisted fallopian tube, showing necrosis and congestion. Note that the ovary (asterisk) and uterus (ut) is totally normal in appearance and a paraovarian cyst is also apparent (arrow).
sudden, right-sided, lower abdominal pain. Her medical history was unremarkable. Physical examination revealed right adnexal tenderness. Ultrasound scan depicted a right-sided, well-circumscribed, purely cystic mass measuring 6 × 6 cm in diameter. There was minimal free fluid in the abdomen. The left ovary and uterus appeared normal on vaginal ultrasonography, but the right ovary could not be visualized. Routine serum biochemistry, hematological evaluation, and tumor markers were all within normal limits. The white blood count was 12,000 mL−1 and axillar temperature was 37 ◦ C. The patient described a similar but less intense pain, which was intermittent in nature, during the last 4 months. During follow-up, as her clinical condition worsened and abdominal guarding and rebound tenderness over a restricted area in the right lower abdominal region developed, laparatomy for a suspected ovarian torsion was performed. At surgery, the right fallopian tube with a paraovarian cyst, twisted two times around its vascular stalk, appeared necrotic and gangrenous. The right ovary was not involved in the pathological process and appeared normal on inspection (Fig. 1). The left tube and ovary, appendix, and uterus were normal. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. The postoperative course was uneventful and the patient was discharged 4 days after surgery. Histopathological examination of the spec-
With an estimated annual incidence of 1 in 1.5 million women, isolated fallopian tube torsion represents an uncommon pathology in the reproductive age [4]. However, its true incidence after menopause has not been established yet. We are aware of only one reported case of isolated fallopian tube torsion after menopause in the English speaking literature [3]. In most of the reported cases of isolated fallopian tube torsion, the right side is more often affected than the left [5]. This could be due to the fact that the mass effect of the sigmoid colon, which is located in the left lower abdomen, might prevent the left tube from twisting around its pedicle. However, the mechanism that leads to isolated fallopian tube torsion is still uncertain. Various suggested theories include anatomic malformations, such as a long mesosalpinx and hydrosalpinx; abnormalities of adjacent organs, such as ovarian and paraovarian masses, uterine enlargement due to pregnancy or tumor, and peri-tubal adhesions; physiologic disturbances in the normal peristaltism of the fallopian tube; hemodynamic alterations causing congestion of the mesosalpingeal veins, as well as previous tubal ligation, trauma or sudden change in body position [6]. The paraovarian cyst may have contributed to the torsion of the fallopian tube in the present case. In most of the cases the presenting symptom is sudden severe lower abdominal pain, which is often accompanied by nausea and vomiting and is located in lower abdomen of the affected side but may radiate to the ipsilateral flank or thigh. As in our patient, in advanced cases peritoneal irritation, with guarding and rebound tenderness may be present, but body temperature, white blood cell count and sedimentation rate are usually within normal range or slightly elevated. As these clinical, laboratory and physical examination findings are non-specific, acute appendicitis, ectopic pregnancy, pelvic inflammatory disease, ovarian torsion, ovarian cyst rupture, intestinal obstruction or perforation, urolithiasis, cystitis, and degeneration of a leiomyoma should be considered in the differential diagnosis of isolated fallopian tube torsion [7].
M.T. Ozgun et al. / Maturitas 57 (2007) 325–327
Isolated tubal torsion should be considered in the differential diagnosis when a patient complaints about severe lower abdominal pain together with a cystic adnexal mass and normal appearing ovaries on ultrasonography. Conservative treatment is possible when definitive diagnosis can be reached before tissue necrosis occurs. This is especially important in younger women, who wish to preserve their further fertility. However, pre-operative diagnosis of isolated tubal torsion is very difficult and the diagnosis usually made during surgical exploration [1]. The management of isolated fallopian tube torsion is surgical, either via laparatomy or laparoscopy. The choice of treatment depends on appearance of the tube in the operation, the patient’s age and reproductive capacity. Due to the pre-operative diagnosis of a suspected ovarian cyst torsion, which might be a malignant process, especially in post-menopausal women, we preferred laparatomy instead of laparoscopy as primary surgical intervention. As many cases are diagnosed beyond the point where a conservative approach might be possible, treatment consists mainly of salpingectomy [8]. Although patients may benefit from simple untwisting of the fallopian tube if there is no apparent ischemic damage [9], the necrotic appearance of the fallopian tube precluded a conservative approach in our case.
327
In conclusion, although it is a rare entity, isolated fallopian tube torsion should be considered in the differential diagnosis of acute lower abdominal pain of post-menopausal women. References [1] Blair CR. Torsion of the fallopian tube. Surg Gynecol Obstet 1962;114:727–30. [2] Filtenborg TA, Hertz JB. Torsion of the fallopian tube. Europ J Obstet Gynec Reprod Biol 1981;12:177–81. [3] Powell JL, Foley GP, Llorens AS. Torsion of the fallopian tube in postmenopausal women. Am J Obstet Gynecol 1972;8: 113–5. [4] Hansen OH. Isolated torsion of the fallopian tube. Acta Obstet Gynecol 1970;49:3–6. [5] Batukan C, Ozgun MT, Turkyilmaz C, Tayyar M. Isolated torsion of the fallopian tube during pregnancy: a case report. J Reprod Med 2007; in press. [6] Bernardus RE, van der Slikke JW, Roex AJM, Dijkhuizen GH, Stolk JG. Torsion of the fallopian tube: some considerations on its etiology. Obstet Gynecol 1984;64:675–7. [7] Ferrera PC, Kass LE, Verdile VP. Torsion of the fallopian tube. Am J Emerg Med 1995;13:312–4. [8] Gross M, Blumstein SL, Chow LC. Isolated fallopian tube torsion: a rare twist on a common theme. AJR Am J Roentgenol 2005;185:1590–2. [9] Raziel A, Mordechai E, Friedler S, Schachter M, Pansky M, RonEl R. Isolated recurrent torsion of the fallopian tube: case report. Hum Reprod 1999;14:3000–1.