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History
 10 years old female patient presented
to ER with severe pelviabdominal pain,
the pain was severe &not relieved by
analgesics,
 she complained of severe vomiting as
well.
Ultrasound
CAT scan of the abdomen
&pelvis
DDx
DDX for other causes of acute
abdomen such as:
DDx for enlarged ovary with multiple
peripheral cysts(follicles) by US:
Appendicitis,acute
1.Ovarian torsion.
Ovarian cysts
2.polycystic ovary disease
Diverticular diseases
3. Ovarian hyper stimulation syndrome
(OHSS)
4. Hemorrhagic ovarian cysts
5-PID
6-Neoplasms rare(primary or secondary
most commonly (lymphoma).
PID
Endometriosis
Pregnancy,Ectopic
Mesenteric ischemia
Pregnancy,UTI
Obstruction,large bowel
UTI ,female
Diagnosis
Ovarian Torsion
 Ovarian torsion is defined as partial or complete rotation of the ovarian
vascular pedicle and causes obstruction to venous outflow and arterial
inflow. Ovarian torsion is usually associated with a cyst or tumor, which is
typically benign; the most common is mature cystic teratoma. Torsion of
a normal ovary is most common among young children, in whom
developmental abnormalities such as excessively long fallopian tubes
may be responsible.
• US features of ovarian torsoion:
*Unilateral enlarged ovary (>4 cm)(The most constant finding in ovarian
torsion ) The volume of the twisted ovary averages 28 times the normal size !!!.
The ovarian stroma may be heterogeneous (2ry to hemorrhage and edema )
String of pearls sign(Peripherally arranged follicles)
Coexistent mass within the twisted ovary
Free pelvic fluid
Twisted vascular pedicle
*Usually located in the midline.
American Journal of Roentgenology
Color Doppler Imaging
The color Doppler low manifestations of ovarian torsion are highly variable and are
based, in part, on the degree of vascular compromise. The classic color Doppler
sonographic finding in ovarian torsion is the absence of arterial low .
The presence of flow color Doppler imaging does not allow exclusion of torsion
but instead suggests that the ovary may be viable, especially if flow is present
centrally. Absence of f low in the twisted vascular pedicle may indicate that the
ovary is not viable.
mymedicineworld.net
Whirlpool Sign
CT findings in ovarian
torsion:
 The role of computed tomography (CT) has
expanded, and it is increasingly used in evaluation
of abdominal pain
Common CT features of ovarian torsion include an
enlarged ovary, uterine deviation to the twisted
side, smooth wall thickening of the
twisted adenxal cystic mass, fallopian tube
thickening, peripheral cystic structures, and ascites.
 Understanding the imaging appearance of
ovarian torsion will lead to conservative, ovarysparing treatment.
radswiki.net
British Journal of Radiology
MRI :
radswiki
DDx
DDx for enlarged ovary with multiple
peripheral cysts(follicles) by US:
1.Ovarian torsion.
2.polycystic ovary disease occurs starting from
menarche till menopause the patient is
usually obese & complaining of hirstusim
,amenorrhea& infertility,enlarged both
ovaries with prominent follicles
3.Ovarian hyper stimulation syndrome (OHSS)
is a rare, potentially fatal, iatrogenic
complication of ovulation stimulation for the
treatment of infertility.
4.Hemorrhagic ovarian cysts are called the
great imitator owing to their multiple
appearances depending on the age of the
hemorrhagic cysts are isoechoic its hard to
DDx it from enlarged ovary only the follow
up which demonstrates resolution of the
cyst.
5-PID
6-Neoplasms rare(primary or secondary most
commonly (lymphoma).