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Isolated Tubal Torsion: CT Features
Clinical Radiology (2001) 56: 155±165 doi:10.1053/crad.1999.0119, available online at http://www.idealibrary.com on
Case Reports Isolated Tubal Torsion: CT Features S . S K I N N E R , F. VOY VO D I C , R . S C RO O P, T. S A N D E R S Division of Medical Imaging, Flinders Medical Centre, Bedford Park 5042, South Australia
Isolated tubal torsion is an uncommon cause of abdominal pain in post-pubertal women and pre-menarcheal girls and is rare in post-menopausal women. Prompt recognition is desirable in order to avoid secondary infarction of the ovary, however, with pain as the only constant clinical sign, diagnosis is often delayed and rare pre-operatively. Ultrasound is often used as the primary investigation in the younger population but in the older woman presenting with a pelvic mass computed tomography (CT) is more often the ®rst line investigation. There has been limited description of the CT features of adnexal torsion. We report a case of proven isolated tubal torsion in a post-menopausal woman. CASE REPORT A 50-year-old post-menopausal woman presented with a 3-day history of left iliac fossa pain of sudden onset associated with a feeling of pressure on micturition. Menopause had occurred 5 years earlier. There was no signi®cant medical or surgical history. With a provisional diagnosis of left renal colic, the patient presented for intravenous pyelography (IVP) which demonstrated a pelvic mass extrinsic to the urinary bladder displacing it to the right side. On further examination per rectum, a 5-cm tender mass was palpable separate to the uterus and the patient was referred for CT of the abdomen and pelvis. Contrast enhanced CT revealed a 5 8 5-cm adnexal mass displacing the uterus anteriorly and to the left which was outlined by thickened broad ligament (Fig. 1a). Density of the mass was slightly greater than unopaci®ed urine. The mass indented the rectosigmoid and displaced uterus and urinary bladder, accounting for the appearance on IVP. Associated in¯ammatory change was seen within adjacent pelvic fat and there was thickening of the uterosacral ligaments (Fig. 1b). At laparotomy 5 days after presentation, a torted left Fallopian tube was found. Both ovaries and the uterus were normal. Left salpingectomy was performed. The ®nal histological report was of extensive infarction secondary to torsion of the left Fallopian tube with haematosalpinx.
DISCUSSION
Symptoms of tubal torsion are non-speci®c, mimicking a wide variety of conditions including acute appendicitis, torted ovarian cyst, tubal pregnancy, ruptured ovarian 0009-9260/01/020155+11 $35.00/0
Fig. 1 ± Consecutive enhanced CT images (10-mm slice thickness) showing (a) uterus and rectosigmoid displaced by low density mass which is outlined by left broad ligament; (b) adjacent in¯ammatory reaction and thickening of uterosacral ligaments. # 2001 The Royal College of Radiologists
156
CLINICAL RADIOLOGY
follicle, pelvic in¯ammatory disease and renal colic. Pain can be of acute onset and constant, as in this case, or be recurrent over a period of months, and there is usually localized abdominal tenderness and a tender adnexal mass. Torsion usually occurs periovulatorily and is extremely rare in post-menopausal women. Torsion of the right Fallopian tube is twice as common as the left [1]. Pathogenesis is not completely understood. Many predisposing factors have been proposed, but generally implicate a pre-existing tubal anatomical or physiological abnormality. Hydrosalpinx, tubal ligation and pelvic adhesions are the more common aetiologies suggested [2]. Torsion of the normal Fallopian tube is exceptional but has been described [1]. Ultrasound is usually the ®rst imaging investigation employed by the clinician in the setting of pelvic pain. The sonographic features of adnexal torsion are well described [2±4]. Typically there is a convoluted cystic adnexal mass with echogenic wall which tapers to the uterine cornu. The mass can also be solid or complex. A normal ipsilateral ovary suggests isolated tubal torsion [2]. Discussion continues in the literature regarding the sensitivity and speci®city of colour Doppler sonography in prediction of viability of the ipsilateral ovary pre-operatively which can be of assistance to the surgeon in determining ovarian viability at surgery. Rosado et al. reported three cases of proven adnexal torsion where pulsed Doppler interrogation revealed a normal waveform and resistive index [5]. Fleischer et al. suggest from their study of 13 patients that the presence of venous ¯ow within the ovary may be a good predictor of viability [6]. There has been limited documentation of the CT ®ndings in adnexal torsion. Ghossain et al. reported a series of 10 patients with surgically proven torsion in which tubal thickening (de®ned as tubal diameter 415 mm) could be detected retrospectively in eight, and tubal haemorrhage
(de®ned as density of 450 HU on unenhanced examinations) in six patients. All of their cases were, however, associated with an ipsilateral adnexal mass [7]. More often, as in this case, the diagnosis of tubal torsion is unsuspected in a post-menopausal woman and contrastenhanced CT is requested to exclude a sinister cause of a pelvic mass. The thickened broad ligament seen to outline the hypodense mass, giving a `rat's tail' appearance, is not a common feature of neoplastic pelvic masses and the presence of streaky soft tissue density in adjacent intrapelvic fat is highly suggestive of an acute in¯ammatory process. We feel that a thickened broad ligament associated with in¯ammatory changes is a further characteristic feature of adnexal torsion on CT. We emphasize that isolated tubal torsion should be considered in the dierential diagnosis of any symptomatic pelvic mass in a post-menopausal woman.
REFERENCES 1 Filtenborg TA, Hertz JB. Torsion of the fallopian tube. Europ J Obstet Gynec Reprod Biol 1981;12:177±181. 2 Baumgartel PB, Fleischer AC, Cullinan JA, et al. Color doppler sonography of tubal torsion. Ultrasound Obstet Gynecol 1996;7: 367±370. 3 Elchalal U, Caspi B, Schachter M, et al. Isolated tubal torsion: clinical and ultrasonographic correlation. J Ultrasound Med 1993;2: 115±117. 4 Caspi B, Ben-Galim P, Weissman A, et al. The engorged fallopian tube: a new sonographic sign for adnexal torsion. J Clin Ultrasound 1995;23:505±507. 5 Rosado WM, Trambert MA, Gosink BB, et al. Adnexal torsion: diagnosis by using doppler sonography. Am J Radiol 1992;159: 1251±1253. 6 Fleischer AC, Stein SM, Cullinan JA, et al. Color doppler sonography of adnexal torsion. J Ultrasound Med 1995;14:523±528. 7 Ghossain MA, Buy J, Bazot M, et al. CT in adnexal torsion with emphasis on tubal ®ndings: correlation with US. J Comput Assist Tomogr 1994;18:619±625.
doi:10.1053/crad.2000.0162, available online at http://www.idealibrary.com on
Cystic Lymphangioma of the Retroperitoneum A . B O N H O M M E , A . B RO E D E R S , R . H OY E N , M . S TA S *, I . D E W E V E R *, A . L . B A E R T Department of Radiology and *Department of Surgical Oncology, University Hospitals, Leuven, Belgium
Cystic lymphangioma is a rare benign cystic lesion. Typical locations include the neck, the axillary area and less frequently the mediastinum and the retroperitoneum. The imaging characteristics of a retroperitoneal cystic lymphanAuthor for correspondence: Prof. Dr R. Oyen, Department of Radiology, University Hospitals, Herestraat 49, B-3000 Leuven (Belgium). Fax: 32 16 343769.
gioma are reported, including magnetic resonance imaging MRI results. CASE REPORT A 59-year-old woman presented with a boring heaviness in the left abdomen over several months. A non-tender and non-pulsating mass
Case Reports Isolated Tubal Torsion: CT Features S . S K I N N E R , F. VOY VO D I C , R . S C RO O P, T. S A N D E R S Division of Medical Imaging, Flinders Medical Centre, Bedford Park 5042, South Australia
Isolated tubal torsion is an uncommon cause of abdominal pain in post-pubertal women and pre-menarcheal girls and is rare in post-menopausal women. Prompt recognition is desirable in order to avoid secondary infarction of the ovary, however, with pain as the only constant clinical sign, diagnosis is often delayed and rare pre-operatively. Ultrasound is often used as the primary investigation in the younger population but in the older woman presenting with a pelvic mass computed tomography (CT) is more often the ®rst line investigation. There has been limited description of the CT features of adnexal torsion. We report a case of proven isolated tubal torsion in a post-menopausal woman. CASE REPORT A 50-year-old post-menopausal woman presented with a 3-day history of left iliac fossa pain of sudden onset associated with a feeling of pressure on micturition. Menopause had occurred 5 years earlier. There was no signi®cant medical or surgical history. With a provisional diagnosis of left renal colic, the patient presented for intravenous pyelography (IVP) which demonstrated a pelvic mass extrinsic to the urinary bladder displacing it to the right side. On further examination per rectum, a 5-cm tender mass was palpable separate to the uterus and the patient was referred for CT of the abdomen and pelvis. Contrast enhanced CT revealed a 5 8 5-cm adnexal mass displacing the uterus anteriorly and to the left which was outlined by thickened broad ligament (Fig. 1a). Density of the mass was slightly greater than unopaci®ed urine. The mass indented the rectosigmoid and displaced uterus and urinary bladder, accounting for the appearance on IVP. Associated in¯ammatory change was seen within adjacent pelvic fat and there was thickening of the uterosacral ligaments (Fig. 1b). At laparotomy 5 days after presentation, a torted left Fallopian tube was found. Both ovaries and the uterus were normal. Left salpingectomy was performed. The ®nal histological report was of extensive infarction secondary to torsion of the left Fallopian tube with haematosalpinx.
DISCUSSION
Symptoms of tubal torsion are non-speci®c, mimicking a wide variety of conditions including acute appendicitis, torted ovarian cyst, tubal pregnancy, ruptured ovarian 0009-9260/01/020155+11 $35.00/0
Fig. 1 ± Consecutive enhanced CT images (10-mm slice thickness) showing (a) uterus and rectosigmoid displaced by low density mass which is outlined by left broad ligament; (b) adjacent in¯ammatory reaction and thickening of uterosacral ligaments. # 2001 The Royal College of Radiologists
156
CLINICAL RADIOLOGY
follicle, pelvic in¯ammatory disease and renal colic. Pain can be of acute onset and constant, as in this case, or be recurrent over a period of months, and there is usually localized abdominal tenderness and a tender adnexal mass. Torsion usually occurs periovulatorily and is extremely rare in post-menopausal women. Torsion of the right Fallopian tube is twice as common as the left [1]. Pathogenesis is not completely understood. Many predisposing factors have been proposed, but generally implicate a pre-existing tubal anatomical or physiological abnormality. Hydrosalpinx, tubal ligation and pelvic adhesions are the more common aetiologies suggested [2]. Torsion of the normal Fallopian tube is exceptional but has been described [1]. Ultrasound is usually the ®rst imaging investigation employed by the clinician in the setting of pelvic pain. The sonographic features of adnexal torsion are well described [2±4]. Typically there is a convoluted cystic adnexal mass with echogenic wall which tapers to the uterine cornu. The mass can also be solid or complex. A normal ipsilateral ovary suggests isolated tubal torsion [2]. Discussion continues in the literature regarding the sensitivity and speci®city of colour Doppler sonography in prediction of viability of the ipsilateral ovary pre-operatively which can be of assistance to the surgeon in determining ovarian viability at surgery. Rosado et al. reported three cases of proven adnexal torsion where pulsed Doppler interrogation revealed a normal waveform and resistive index [5]. Fleischer et al. suggest from their study of 13 patients that the presence of venous ¯ow within the ovary may be a good predictor of viability [6]. There has been limited documentation of the CT ®ndings in adnexal torsion. Ghossain et al. reported a series of 10 patients with surgically proven torsion in which tubal thickening (de®ned as tubal diameter 415 mm) could be detected retrospectively in eight, and tubal haemorrhage
(de®ned as density of 450 HU on unenhanced examinations) in six patients. All of their cases were, however, associated with an ipsilateral adnexal mass [7]. More often, as in this case, the diagnosis of tubal torsion is unsuspected in a post-menopausal woman and contrastenhanced CT is requested to exclude a sinister cause of a pelvic mass. The thickened broad ligament seen to outline the hypodense mass, giving a `rat's tail' appearance, is not a common feature of neoplastic pelvic masses and the presence of streaky soft tissue density in adjacent intrapelvic fat is highly suggestive of an acute in¯ammatory process. We feel that a thickened broad ligament associated with in¯ammatory changes is a further characteristic feature of adnexal torsion on CT. We emphasize that isolated tubal torsion should be considered in the dierential diagnosis of any symptomatic pelvic mass in a post-menopausal woman.
REFERENCES 1 Filtenborg TA, Hertz JB. Torsion of the fallopian tube. Europ J Obstet Gynec Reprod Biol 1981;12:177±181. 2 Baumgartel PB, Fleischer AC, Cullinan JA, et al. Color doppler sonography of tubal torsion. Ultrasound Obstet Gynecol 1996;7: 367±370. 3 Elchalal U, Caspi B, Schachter M, et al. Isolated tubal torsion: clinical and ultrasonographic correlation. J Ultrasound Med 1993;2: 115±117. 4 Caspi B, Ben-Galim P, Weissman A, et al. The engorged fallopian tube: a new sonographic sign for adnexal torsion. J Clin Ultrasound 1995;23:505±507. 5 Rosado WM, Trambert MA, Gosink BB, et al. Adnexal torsion: diagnosis by using doppler sonography. Am J Radiol 1992;159: 1251±1253. 6 Fleischer AC, Stein SM, Cullinan JA, et al. Color doppler sonography of adnexal torsion. J Ultrasound Med 1995;14:523±528. 7 Ghossain MA, Buy J, Bazot M, et al. CT in adnexal torsion with emphasis on tubal ®ndings: correlation with US. J Comput Assist Tomogr 1994;18:619±625.
doi:10.1053/crad.2000.0162, available online at http://www.idealibrary.com on
Cystic Lymphangioma of the Retroperitoneum A . B O N H O M M E , A . B RO E D E R S , R . H OY E N , M . S TA S *, I . D E W E V E R *, A . L . B A E R T Department of Radiology and *Department of Surgical Oncology, University Hospitals, Leuven, Belgium
Cystic lymphangioma is a rare benign cystic lesion. Typical locations include the neck, the axillary area and less frequently the mediastinum and the retroperitoneum. The imaging characteristics of a retroperitoneal cystic lymphanAuthor for correspondence: Prof. Dr R. Oyen, Department of Radiology, University Hospitals, Herestraat 49, B-3000 Leuven (Belgium). Fax: 32 16 343769.
gioma are reported, including magnetic resonance imaging MRI results. CASE REPORT A 59-year-old woman presented with a boring heaviness in the left abdomen over several months. A non-tender and non-pulsating mass