Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Ovarian Torsion - The Acute Surgical Abdomen

Patient Demographics

  • Age: 22 years
  • Sex: Female
  • Occupation: College student

Chief Complaint

"The pain in my side is unbearable and I keep throwing up."

History of Present Illness

A 22-year-old female presents with sudden onset of severe right lower quadrant pain that began 6 hours ago. Pain is constant, sharp, and radiates to her back. She has had 5 episodes of vomiting. She was in her normal state of health prior to onset. She denies fever or urinary symptoms. LMP was 2 weeks ago, and she has a history of an ovarian cyst found incidentally 6 months ago on imaging for unrelated symptoms.

Initial Assessment

ESI Level: 2 - Severe pain, potential surgical emergency

First Impression:

  • Appearance: Writhing in pain, pale, diaphoretic
  • Work of breathing: Normal, but splinting due to pain
  • Circulation: Pale but well-perfused

Vital Signs:

  • Heart rate: 108 bpm
  • Blood pressure: 138/82 mmHg (pain response)
  • Respiratory rate: 20 breaths/min
  • SpO2: 99% on room air
  • Temperature: 37.3C

Primary Survey

Airway: Patent Breathing: Normal effort Circulation: Tachycardic (pain), good perfusion Disability: Alert, GCS 15, severe pain (10/10) Exposure: No abnormalities

Key Clinical Feature: Waxing and Waning Pain

Patient reports the pain is constant but with episodes of more severe "waves" - this pattern is classic for torsion (intermittent torsion/detorsion)

Secondary Survey

SAMPLE History:

  • Symptoms: Sudden RLQ pain, nausea/vomiting, no fever
  • Allergies: None
  • Medications: Oral contraceptives
  • PMH: 5cm right ovarian cyst on US 6 months ago (was to follow up but didn't)
  • LMP: 2 weeks ago, regular cycles
  • Last Meal: Breakfast this morning
  • Events: Sudden onset during class

Risk Factors for Ovarian Torsion:

  • Ovarian cyst/mass >5cm - YES (known cyst)
  • Ovarian hyperstimulation - No
  • Pregnancy - Pending test
  • Prior torsion - No

Physical Examination:

Abdominal:

  • RLQ tenderness with guarding
  • No rebound (early)
  • No peritoneal signs
  • Normoactive bowel sounds

Pelvic Exam:

  • External: Normal
  • Speculum: No discharge or bleeding
  • Bimanual: Right adnexal tenderness and fullness, cervical motion tenderness minimal

Diagnostic Testing

Point-of-Care:

  • Urine pregnancy test: Negative
  • Urinalysis: Normal (ruling out UTI/stone)

Labs:

  • CBC: WBC 12.4, Hgb 12.8
  • BMP: Normal
  • Lipase: Normal

Pelvic Ultrasound with Doppler:

  • Right ovary enlarged (8cm) with peripheral follicles ("string of pearls")
  • Complex cystic structure within right ovary
  • Absent Doppler flow to right ovary - CRITICAL FINDING
  • Left ovary normal
  • No free fluid

Diagnosis

Right ovarian torsion (likely on background of ovarian cyst)

Management

Time-Sensitive Surgical Emergency:

  • Ovarian viability decreases with time
  • Goal: Detorsion within 6-8 hours for best salvage rate

Pre-Operative:

  1. NPO status
  2. IV fluid hydration
  3. Pain management: Morphine 4mg IV + Ketorolac 30mg IV
  4. Antiemetic: Ondansetron 4mg IV
  5. Emergent OB/GYN consultation

Surgical Management:

  • Diagnostic laparoscopy
  • Right ovarian torsion confirmed (720-degree twist)
  • Ovary initially dusky/blue
  • Detorsion performed
  • Ovary observed - color improved over 10 minutes
  • Ovarian cystectomy performed (dermoid cyst found)
  • Ovary preserved (oophoropexy considered but not performed)

Disposition

  • Post-operative recovery
  • Oral intake tolerated
  • Discharged home POD 1
  • OB/GYN follow-up in 2 weeks
  • Education on warning signs of recurrence

Teaching Points

  1. Think torsion in young women with acute unilateral pelvic pain and vomiting
  2. Ovarian cysts/masses are risk factors: Cysts >5cm more likely to torse
  3. Doppler ultrasound: Absent or decreased flow is concerning, but presence of flow doesn't rule out torsion (intermittent)
  4. "Whirlpool sign": Twisted vascular pedicle on ultrasound is pathognomonic
  5. Surgery is diagnostic AND therapeutic: Don't delay for definitive imaging if clinical suspicion high
  6. Ovarian salvage possible: Even dusky-appearing ovaries often recover after detorsion
  7. Pregnancy increases risk: Corpus luteum cysts and hormonal changes predispose to torsion
  8. Recurrence: 10% risk; consider oophoropexy in high-risk patients

Clinical Image

Image Description: Transvaginal ultrasound with Doppler demonstrating an enlarged ovary with peripheral follicles and absent central Doppler flow (arrow), consistent with ovarian torsion.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Amanda Er. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/ovarian-torsion-ultrasound-1

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