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Age: 23

Sex: Female

Indication: Right lower quadrant pain

Negative pregnancy test

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Case #16


Findings

  • Markedly enlarged right ovary with heterogeneous echotexture, peripheralization of ovarian follicles, and minimal internal vascularity
  • Echogenic mass along the medial aspect of the right ovary with internal “dot dash” appearance
  • Normal appearance of the uterus and left ovary
  • Moderate volume of mildly complex fluid layering in the cul-de-sac


Diagnosis

Ovarian torsion

Sample Report

Markedly enlarged right ovary with heterogeneous echotexture, peripheralization of ovarian follicles, and minimal internal vascularity, concerning for ovarian torsion.

Echogenic mass along the medial aspect of the right ovary with internal “dot dash” appearance is consistent with a dermoid cyst and is the likely lead point for ovarian torsion.

Normal appearance of the uterus and left ovary.

Moderate volume of mildly complex fluid layering in the cul-de-sac.


Discussion

  • Ovarian torsion is a feared cause for lower abdominal pain, which like testicular torsion requires quick intervention to prevent tissue necrosis
  • Ovarian torsion results as the ovary rotates causing twisting of the vascular pedicle in the suspensory ligament
  • Ovarian masses (like the dermoid cyst in this case) predispose to torsion by making the ovary unbalanced and more likely to rotate
  • Venous and lymphatic outflow are occluded first resulting in swelling of the ovary. Arterial obstruction or thrombosis come later
  • Remember that the ovary has a dual blood supply (primary supply from the ovarian artery with a contribution from the uterine artery), so preservation of internal blood flow does NOT exclude ovarian torsion
  • Ultrasound findings supportive of a diagnosis of ovarian torsion include:
    • Enlarged ovary (> 4 cm) – the most reliable and early finding
      • Remember, though, that when the ovary is measured inclusive of an ovarian mass, it will often measure enlarged even when there is no acute pathology
    • Medial positioning of the ovary, often superior to the uterus
    • Peripheralization of ovarian follicles (this appearance can also be seen with polycystic ovarian disease)
    • Twisting of the vascular pedicle in the ovarian suspensory ligament
    • Free pelvic fluid, which may contain blood
  • Ovarian dermoid cysts are the most common masses to serve as lead points for ovarian torsion
    • Look for internal echogenic material (fat), shadowing (related to calcification), and the “dot dash” appearance related to hair within the mass


Images

Enlarged right ovary with peripheralization of ovarian follicles (red arrows) and near complete loss of internal ovarian vascularity, consistent with ovarian torsion. Heterogeneous echogenic mass along the medial aspect of the right ovary with internal echogenic dots (red arrows) and dashes (yellow arrows), consistent with a dermoid cyst.

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