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5MMMM��������������������������������������������������������������������b9?????????��: Isolated tubal torsion in postmenopausal woman

Abstract:

Introduction:
 Isolated torsion of the fallopian tube is an uncommon cause of lower abdominal pain, and these cases were reported to be seen mostly in the reproductive period, while quite rare before menarche and postmenopause.

Presentation of Case:
 A 49-year-old multiparous postmenopausal woman, admitted to our hospital with the complaint of lower abdominal pain, nausea and vomiting. According to physical examination, laboratory tests and imaging analysis, pelvic abscess was suspected. Laparotomy revealed isolated torsion of the right fallopian tube, and the mass was found adherent to the rectosigmoid and appendix.

Discussion: 
 Isolated tubal torsion has no pathognomonic clinical findings. Usually these cases may mimic an acute abdomen, and may be misdiagnosed as torsion of ovarian cyst, ectopic pregnancy, PID, acute appendicitis, degenerated myoma (6-8). In differential diagnosis, imaging methods such as, ultrasonography, computerized tomography and magnetic resonance imaging are widely used. Laparoscopy or laparotomy should be performed for definitive diagnosis.

Conclusion:  
 Isolated torsion of fallopian tube may be confused with many clinical situations causing pelvic or abdominal pain. Preoperative diagnosis is highly difficult. Imaging techniques and clinical findings are used in the differential diagnosis. Isolated torsion of fallopian tube should be considered in the differential diagnosis in female patients presenting acute lower abdominal pain, even in postmenopausal period.


Keywords: pelvic pain, tubal torsion, postmenopausal period

Introduction:

   Isolated torsion of the fallopian tube is an uncommon cause of lower abdominal pain, and was first reported by Bland-Sutton in 1890 (1). Reported incidence in literature is 1/ 1,500,000 (2,3) .  These cases were reported to be seen mostly in the reproductive period, while quite rare before menarche and postmenopause (4,5). Preoperative diagnosis is difficult. Definitive diagnosis can be largely established intraoperatively through laparoscopy or laparotomy. Due to its rarity we present a 49-year-old postmenopausal patient with tubal torsion in this manuscript.

Presentation of Case:

    A 49-year-old women who had nausea, vomiting and lower abdominal pain started three days ago and gradually localized to the right lower quadrant. Vital signs; TA:110/70 mmHg, Pulse:85/min, Fever:37.2 c. Physical examination revealed tenderness at both lower quadrants, without rebound and defence. Vaginal examination and transvaginal ultrasonography (TvUSG)  manifested a heterogeneous 7 cm  cystic mass containing septations at   the right adnexa, normal findings regarding uterus size and left ovary and adnexa. Free fluid was not detected in the pouch of Douglas. Laboratory parameters showed leukocytosis and high erythrocyte sedimentation rate. ( Table 1) Computerized Tomography (CT) revealed a heterogeneous 7.5 cm in size cystic mass was detected at   the right adnexa. As a result of USG and CT imaging, pelvic infection or hemorhagic cyst was considered. As  rebound and defense emerged after 12 hours of hospitalization, explorative laparotomy was performed. The uterus, ovaries and left fallopian tube were found to be normal. However, the right fallopian tube created a 7-8 cm mass and was twisted three times around itself. The mass was observed  to be adherent to the rectosigmoid and appendix.  Adhesiolysis was performed to release the mass. Rectum and sigmoid colon  were both partially lacerated during adhesiolysis. Salpingectomy was the treatment of choice since the tube was gangrenous, and the patient was postmenopausal. ( Figure 1,2) Consequently, primary repair of rectum and sigmoid colon injury was performed. Histopathological examination revealed no pathology, except necrotic tuba. The patient was discharged on 7th postoperative day, with complete resolution. 

Discussion 

    Isolated torsion of the fallopian tubes is a rare gynecologic cause of lower abdominal pain. Most cases reported in the literature were in reproductive period, while postmenopausal cases were very rare. 
    Etiological factors are as follows; congenital tubal anomalies, acquired anatomic abnormalities (hematosalpinx, hydrosalpinx), tubal ligation, abnormal peristaltism (autonomic dysfunction, or drugs), previous pelvic surgery, pelvic inflamatoury disease , pregnancy, adhesions, paraovarian, ovarian and tubal masses. 
     Isolated tubal torsion has no pathognomonic clinical findings. Usually these cases may mimic an acute abdomen, and may be misdiagnosed as torsion of ovarian cyst, ectopic pregnancy, PID, acute appendicitis, degenerated myoma (6-8). In differential diagnosis, imaging methods such as, ultrasonography, computerized tomography and magnetic resonance imaging are widely used. 
     Isolated torsion of fallopian tubes usually presents with acute abdominal or pelvic pain. Vaginal bleeding, fever, nausea, vomiting, anorexia, urinary symptoms may be coexisting (9). Elevated erythrocyte sedimentation rate and increased C-reactive protein and leukocytosis may be found in laboratory evaluation. 
     In the diagnosis of isolated fallopian tube torsion, imaging methods, USG, Doppler USG, CT and MRI are used. Imaging methods demonstrate non-specific findings in tubal torsion, moreover clinical correlation is required. The differential diagnosis of isolated tubal torsion by using imaging methods should include degenerative leiomyoma, PID, torsion of ovarian cyst, acute appendicitis, and ectopic pregnancy. Dilated fallopian tube with a hyperechoic wall, accompanied by ipsilateral normal appearing ovary, may be detected sonographically. In one study, Doppler USG of tubal torsion, especially in cases with a history of tubal ligation, indicated high-impedance and absence of flow in tubuler structure (10).  The sonographic whirlpool sign, that can be visible with endovaginal prob movements, has  been shown to be helpful in the diagnosis of fallopian tube torsion (5,11). MRI or CT may be contributory in def1n1ng the torsion. Tubal coiling or loss of tubal wall enhancement may be seen in MRI (12-15). Additionally, free intrapelvic fluid, thickening of the broad ligament, signs of regional ileus may be observed (16). 
     Laparoscopy or laparotomy should be performed for definitive diagnosis. Tubal detorsion is the treatment of choice for the reproductive age patients having a fine, healthy fallopian tube. Salpingectomy is performed in cases with necrotic, or gangrenous tubes, and tubal or ovarian neoplasms (Reported 23-30). For postmenopausal women with lower abdominal pain or an adnexial mass, isolated fallopian tube torsion should also be considered in the differential diagnosis. 

Conclusion:  	
    
    Isolated torsion of fallopian tube may be confused with many clinical situations causing pelvic or abdominal pain. Preoperative diagnosis is highly difficult. Imaging techniques and clinical findings are used in the differential diagnosis. Isolated torsion of fallopian tube should be considered in the differential diagnosis in female patients presenting acute lower abdominal pain, even in postmenopausal period.

Consent:

   Written informed consent was obtained from the patient for publication of this case report and case series and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request

Conflict of interest statement: 


   We have no financial or commercial conflicts of interest.











References

1. Bland-Sutton T. Salpingitis and some of its effects. Lancet 1890;2:1146
2. Origoni M, Cavoretto P, Conti E, Ferrari A. Isolated tubal torsion in pregnancy. Eur J Obstet Gynecol Reprod Biol. 2009:116-20
3. Hansen OH. Isolated torsion of the fallopian tube. Acta Obstet Gynecol Scand 1970;49:3-6
4. Kurzbart E, Mares AJ, Cohen Z, Mordehai J, Finaly R. Isolated torsion of the fallopian tube in premenarcheal girls. J Pediatr Surg 1994;29(10):1384-1385
5. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallopian tube The Sonographic Whirlpool Sign. J Ultrasound Med 2009;28:657-662 
6. Maynard SR, Peipert JF, Brody JM. Tubal torsion appearing as acute pelvic inflammatory disease. J Am Assoc Gynecol Laparosc 1996;3:431-433
7.  Krissi H, Shalev J, Bar-Hava I, Langer R, Herman A, Kaplan B. Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract 2001;14:274-277
8. Shukla R. Isolated torsion of the hydrosalpinx: a rare presentation. Br J Radiol 
2004; 77:784-786
9. Krissi H, Shalev J, Bar-Hava I. Fallopian tube torsion: laparoscopic evaluation and treatment of a rare gynecological entity. J Am Board Fam Pract. 2001;14:274-7
10. Milki A, Jacobson DH. Isolated torsion of fallopian tube. A case report. J Reprod Med 1998;43:836-8
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$dha$gd3$dha$gd��11. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallopian tube: the sonographic whirlpool sign. J Ultrasound Med 2009;28(5):657-662
12. Harmon JC, Binkovitz LA, Binkovitz LE. Isolated fallopian tube torsion: sonographic and CT features . Pediatr Radiol 2008;38(2):175-179 
13. Merlini L, Anooshiravani M, Vunda A, Borzani I, Napolitano M, Hanquinet S. Noninflammatory fallopian tube pathology in children. Pediatr Raiol 2008;38(12):1330-1337
14. Orazi C, Insera A, Lucchetti MC, Schingo PM. Isolated tubal torsion: a rare cause of pelvic pain at menarche. Sonographic and MR findings. Pediatr Radiol 
2006;36(12):1316-1318
15.Park BK, Kim CK, Kim B. Isolated tubal torsion: spesific signs on preoperative computed tomography and magnetic resonance imaging. Acta Radiol 2008;2:233-235
16. Markhardt BK, Jones L, Drugas GT. Isolated torsion of the fallopian tube in a menarchal 11-year-old girl. Pediatr Emerg Care 2008;24(6):374-376
FIGURE LEGENDS:


FIGURE 1: Right adnexial area with necrotic  fallopian tube

FIGURE 2: Necrotic right fallopian tube after salphenjectomy 





















 PAGE   \* MERGEFORMAT 1








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