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Torsion of fallopian tube
TORSION ERWIN T.
MICHAELSON,
OF FALLOPIAN M.D.,
~~OC~VII,LF:
TUBE (!ENTRE,
N.
\1-.
ORSION of a tube is not a rare condition, but torsion of a previously undiseased tube ix. Kegad, in discussing the relat.ive frequency of torsion of t.hr tube based on 101 cases, fount1 torsion of the undisease~l tube in 24 per rent of the cases. llowevor, histologic examination was done in only 8 per cent of these. It is ni?’ hriief t,hat, Irad it been done in more of these, there would have been found a smaller llercentage of previously undiseased tubes. He found torsion of a hydrosalpinx in 18 per cent, torsion in hernial sac in 1.l per cent, torsion in salpingitis, eetopic, or tumor in 13.5 per cent; torsion in the course of pregnancy in 12 per cent, with various other conditions making ~11 the additional percemage. Andersonz reports the torsion of an apparently normal ovary and spontaneous amputation of the tube occurring in a l2-pear-old girl with a one-day history of pain. In this case the tube was amputated 1.5 cm. from the cornu. IZaminester3 reported the case of a Z-&year-old patient; gravida i, para i, with a twist due to a small parovarian cyst. Goldberg and Olin14 reported a case due to twisted hydrosalpinx. Ravages reported a case of n twisted hematosalpinx complicating pregnsncp. That case was the fifteenth reported up to that time. !I’he case to he rrportecl here is that, of a torsion of :I previously untliseasecl tube.
T
Case History Mrs. J. M., a 37.year-old gravida ii, para ii, was admitted to t,he South Nassau Commuities Hospital complaining of pain in the right lower quadrant of three days’ duration. PRGent’s periods began at 15ys years and were always regular until last pregnancy. Since then she has on several occasions been as much RR two days late. Patient had a normal period in April, 1947. Her May period, howevet, was five ~lwys late, occurring on May 30, and being normal in amount and duration. The evening of .Junr 15, she developed pain in lower abdomen particularly on the right side. The pain became severe .&ring the night. Findings were: normal pulse and temperature, a soft abdomen, with slight tenderness in the right lower quadrant. iz white blood cell count and differential count done the next day were normal. Patient, however, continued to have intermittent pain in the lower abdomen on June 16 and 17. Early on the morning of the 18th, she had more severe pain and while in the bathroom actually fainted. At this time she was seen in consultation, and the significant findings were a temperature of 1000 F., pulse 100. The abdomen showed definite spasm and rigidity of the lower quadrants, particularly on the right side. There was direct tenderness in the right lower quadrant hut even more marked rebound tenderness. External genitals were normal ; cervix not particIn the right fornix was a mass measuring about ularly soft; fundus of normal size and firm. 6 by S cm. This was exquisitely tender and felt cystic. There was no blood on the examining finger. With these findings, patient was admitted to hospital with a diagnosis of either or, a twisted right ovarian cyst. a right ectopic pregnancy, with tubal abortion, L&oratory DO&Z: The red blood count was 4.1 million, hemoglobin 82 per cent, white blood count 9,000 with 80 per cent polymorphonuclear leucocytes. The urine was negative. Patient was operated upon shortly after admission to the hospital. Upon opening the peritoneal cavity, it was noted that there was an increased amount of fluid, culture of There was no blood in the peritoneal which was taken, and subsequently found to be sterile. cavity. The only pathologic finding was that in the right tube. This showed two complete The proximal portion of the tube appeared normal. twists upon itself at the midportion. The The flmbriatad end was closed. distal half, however, was much dilated measuring 8 by 8 cm. The dilated portion of the tube was tense, cystic, and showed bluish-red discoloration. A right salpingectomy was done. 794
Volume 56 Number 4
TORSION
OF
FALLOPIAN
795
TUBE
Pathologic Rewrt.-Specimen consists of a tube, the proximal portion pears ndrmal. The distal half is dilated, measuring 6 by 8 cm. The fimbriated Section of the dilated portion of the tube reveals the presence of serosanguineous is also some clotted blood present in the lumen and wall of the tube. Diagnosis.-Twisted hematosalpinx. Patient had an uneventful convalescence. The wound healed by primary patient was discharged on the eighth postoperative day.
of which apend is closed. fluid. There
union
and
the
Comment The case presented is one of torsion in a previously undiseased tube. This is corroborated by the finding of normal tubal lining and diameter in the portion of the tube proximal to the The normal appearance of the other tube, plus the fact that the patient has two twist. young children, likewise point to a conclusion that the tube was normal prior to the present episode. The exact frequency of occurrence of this condition in a nondiseased tube is difficult to determine because the pathologic examination is frequently inaccurate, the marked necrosis usually present obscuring the rest of the picture. Blum and Sayre,e in their article, review the various theories as to the possible mechanism of this condition. Of the various theories postulated, the following impressed me as being the most likely: 1. Anatomic theory, which states that malformations in the mesosalpinx or the tube favor torsion, e.g., long mesosalpinx, hydatids of Morgagni, persistence of the spiral winding normally present in the tube of the fetus. 2. Physiologic theory that a disturbance of the regular peristaltic movements of the tube, such as spasm, may give this condition. 3. Hemodynamic. The veins of the mesosalpinx are longer and more flexible than the arteries, and, in case of venous congestion, they assume a spiral course which favors torsion. 4. Sellheim’s theory that sudden changes or stoppage of body movement may give rise to torsion. The known. account
reason for the occurrence of this There was nothing in the patient’s for the occurrence of this condition.
condition previous
in the present ease must history or in the operative
remain findings
References 1. 2. 3. 4. 5. 6.
Regad, J.: Gyn6c. et obst. 27: 519-535, 1933. Anderson, Harley E.: AM. J. OBST. & GYNEC. 49: 283, 1945. Kaminester, Sanfor,d: AM. J. OBST. & GYNEC. 36: 516, 1938. Goldberg, Samuel L., and Olim, Charles: AM. J. OBST. & GYNEC. Savage, J. E.: AM. J. OBST. & GYNEC. 32: 1043-1047, 1936. Blum, L. L., and Sayre, B. E.: Arch. Surg. 34: 1032-1048, 1937. 2 ROXBURY
ROAD
36:
699,
1938,
unto
MICHAELSON,
OF FALLOPIAN M.D.,
~~OC~VII,LF:
TUBE (!ENTRE,
N.
\1-.
ORSION of a tube is not a rare condition, but torsion of a previously undiseased tube ix. Kegad, in discussing the relat.ive frequency of torsion of t.hr tube based on 101 cases, fount1 torsion of the undisease~l tube in 24 per rent of the cases. llowevor, histologic examination was done in only 8 per cent of these. It is ni?’ hriief t,hat, Irad it been done in more of these, there would have been found a smaller llercentage of previously undiseased tubes. He found torsion of a hydrosalpinx in 18 per cent, torsion in hernial sac in 1.l per cent, torsion in salpingitis, eetopic, or tumor in 13.5 per cent; torsion in the course of pregnancy in 12 per cent, with various other conditions making ~11 the additional percemage. Andersonz reports the torsion of an apparently normal ovary and spontaneous amputation of the tube occurring in a l2-pear-old girl with a one-day history of pain. In this case the tube was amputated 1.5 cm. from the cornu. IZaminester3 reported the case of a Z-&year-old patient; gravida i, para i, with a twist due to a small parovarian cyst. Goldberg and Olin14 reported a case due to twisted hydrosalpinx. Ravages reported a case of n twisted hematosalpinx complicating pregnsncp. That case was the fifteenth reported up to that time. !I’he case to he rrportecl here is that, of a torsion of :I previously untliseasecl tube.
T
Case History Mrs. J. M., a 37.year-old gravida ii, para ii, was admitted to t,he South Nassau Commuities Hospital complaining of pain in the right lower quadrant of three days’ duration. PRGent’s periods began at 15ys years and were always regular until last pregnancy. Since then she has on several occasions been as much RR two days late. Patient had a normal period in April, 1947. Her May period, howevet, was five ~lwys late, occurring on May 30, and being normal in amount and duration. The evening of .Junr 15, she developed pain in lower abdomen particularly on the right side. The pain became severe .&ring the night. Findings were: normal pulse and temperature, a soft abdomen, with slight tenderness in the right lower quadrant. iz white blood cell count and differential count done the next day were normal. Patient, however, continued to have intermittent pain in the lower abdomen on June 16 and 17. Early on the morning of the 18th, she had more severe pain and while in the bathroom actually fainted. At this time she was seen in consultation, and the significant findings were a temperature of 1000 F., pulse 100. The abdomen showed definite spasm and rigidity of the lower quadrants, particularly on the right side. There was direct tenderness in the right lower quadrant hut even more marked rebound tenderness. External genitals were normal ; cervix not particIn the right fornix was a mass measuring about ularly soft; fundus of normal size and firm. 6 by S cm. This was exquisitely tender and felt cystic. There was no blood on the examining finger. With these findings, patient was admitted to hospital with a diagnosis of either or, a twisted right ovarian cyst. a right ectopic pregnancy, with tubal abortion, L&oratory DO&Z: The red blood count was 4.1 million, hemoglobin 82 per cent, white blood count 9,000 with 80 per cent polymorphonuclear leucocytes. The urine was negative. Patient was operated upon shortly after admission to the hospital. Upon opening the peritoneal cavity, it was noted that there was an increased amount of fluid, culture of There was no blood in the peritoneal which was taken, and subsequently found to be sterile. cavity. The only pathologic finding was that in the right tube. This showed two complete The proximal portion of the tube appeared normal. twists upon itself at the midportion. The The flmbriatad end was closed. distal half, however, was much dilated measuring 8 by 8 cm. The dilated portion of the tube was tense, cystic, and showed bluish-red discoloration. A right salpingectomy was done. 794
Volume 56 Number 4
TORSION
OF
FALLOPIAN
795
TUBE
Pathologic Rewrt.-Specimen consists of a tube, the proximal portion pears ndrmal. The distal half is dilated, measuring 6 by 8 cm. The fimbriated Section of the dilated portion of the tube reveals the presence of serosanguineous is also some clotted blood present in the lumen and wall of the tube. Diagnosis.-Twisted hematosalpinx. Patient had an uneventful convalescence. The wound healed by primary patient was discharged on the eighth postoperative day.
of which apend is closed. fluid. There
union
and
the
Comment The case presented is one of torsion in a previously undiseased tube. This is corroborated by the finding of normal tubal lining and diameter in the portion of the tube proximal to the The normal appearance of the other tube, plus the fact that the patient has two twist. young children, likewise point to a conclusion that the tube was normal prior to the present episode. The exact frequency of occurrence of this condition in a nondiseased tube is difficult to determine because the pathologic examination is frequently inaccurate, the marked necrosis usually present obscuring the rest of the picture. Blum and Sayre,e in their article, review the various theories as to the possible mechanism of this condition. Of the various theories postulated, the following impressed me as being the most likely: 1. Anatomic theory, which states that malformations in the mesosalpinx or the tube favor torsion, e.g., long mesosalpinx, hydatids of Morgagni, persistence of the spiral winding normally present in the tube of the fetus. 2. Physiologic theory that a disturbance of the regular peristaltic movements of the tube, such as spasm, may give this condition. 3. Hemodynamic. The veins of the mesosalpinx are longer and more flexible than the arteries, and, in case of venous congestion, they assume a spiral course which favors torsion. 4. Sellheim’s theory that sudden changes or stoppage of body movement may give rise to torsion. The known. account
reason for the occurrence of this There was nothing in the patient’s for the occurrence of this condition.
condition previous
in the present ease must history or in the operative
remain findings
References 1. 2. 3. 4. 5. 6.
Regad, J.: Gyn6c. et obst. 27: 519-535, 1933. Anderson, Harley E.: AM. J. OBST. & GYNEC. 49: 283, 1945. Kaminester, Sanfor,d: AM. J. OBST. & GYNEC. 36: 516, 1938. Goldberg, Samuel L., and Olim, Charles: AM. J. OBST. & GYNEC. Savage, J. E.: AM. J. OBST. & GYNEC. 32: 1043-1047, 1936. Blum, L. L., and Sayre, B. E.: Arch. Surg. 34: 1032-1048, 1937. 2 ROXBURY
ROAD
36:
699,
1938,
unto