DOI:10.2214/AJR.04.1646
AJR 2005; 185:1590-1592
© American Roentgen Ray Society
Isolated Fallopian Tube Torsion: A Rare Twist on a Common Theme
Megan Gross1,
Sylvie L. Blumstein2 and
Lawrence C. Chow1,3
1 Department of Radiology, Stanford University School of Medicine, Stanford, CA
94305.
2 Department of Obstetrics and Gynecology, Stanford University School of
Medicine, Stanford, CA 94305.
Received October 22, 2004;
accepted after revision December 6, 2004.
Address correspondence to L. C. Chow
(chowl{at}ohsu.edu).
3 Present address: Department of Radiology, Oregon Health and Science
University, 3181 SW Sam Jackson Park Rd. L340, Portland, OR 97201.
Introduction
Acute pelvic pain in a nonpregnant female patient is a common
clinical scenario with a broad clinical differential diagnosis. Such patients
are frequently referred for sonography to evaluate the adnexa, in particular
for the identification of ovarian torsion that demands early surgical
intervention. We encountered a case of isolated fallopian tube torsion in a
patient with a normal, nontorsed ipsilateral ovary.
Case Report
A 25-year-old gravida 0 woman presented to the emergency department with a
chief complaint of pelvic pain. On the day before presentation, the patient
experienced sudden onset of severe, bilateral lower quadrant pain while
jogging. The patient reported doubling over in pain and then resting until the
pain slowly resolved. The pain recurred the next day, equal in intensity, and
then localized to the right lower quadrant. She reported no significant
medical history; surgical history was notable for an appendectomy in
childhood. The patient reported being sexually active but denied use of birth
control. She took no regular medications and had annual gynecologic
examinations with a history of normal Pap smears. On evaluation, the patient
was afebrile and had a blood pressure of 97 over 54 mm Hg with a pulse of 79.
Physical examination was significant for right adnexal fullness, rebound
tenderness in the right lower quadrant, and normal bowel sounds. Complete
blood count, urinalysis, and serum chemistries were normal and urine pregnancy
test was negative. Endocervical swabs were obtained and sent for culture.
Sonography examination (Figs.
1A and
1B) showed a normal uterus and
a normal right ovary with arterial and venous waveforms on spectral Doppler;
however, a normal left ovary was not visualized. A midline cystic mass
measuring 6.1 x 4.8 x 6.5 cm anterior to the uterus was thought to
arise from the left adnexa or ovary, but careful examination of this structure
revealed a beaked, tapering appearance, pointing toward the right adnexa. A
small amount of simple free fluid was present within the pelvis. CT
examination (Figs. 1C and
1D) showed two normal ovaries
and free pelvic fluid. Most notably, there was a dilated right adnexal tubular
structure that flared at one end to a maximal dimension of 6.0 x 7.2 cm,
suspicious for hydrosalpinx. Again, a beaked appearance of the tube, with its
vertex centered in the right adnexa, was present.
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Fig. 1A —25-year-old woman with acute pelvic pain. Pelvic sonogram
shows normal-appearing right ovary with several follicles of varying sizes.
Color and spectral Doppler images of ovary depicted normal venous and arterial
(not shown) flow, excluding diagnosis of ovarian torsion.
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Fig. 1B —25-year-old woman with acute pelvic pain. Midline cystic mass
is seen with gray-scale sonography anterior to uterus with region of
progressive narrowing as it courses toward right adnexa (arrow).
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Fig. 1C —25-year-old woman with acute pelvic pain. Axial
contrast-enhanced CT images show midline fluid-attenuation mass
(asterisk) with progressive narrowing and focal beak sign
(arrow, D) centered in ipsilateral adnexa within lower right
hemipelvis, representing dilated, torsed right fallopian tube. Portion of tube
opposite point of torsion (arrows, C) is seen and is dilated
to lesser degree. Small amount of free fluid (arrowheads, C)
is present within right hemipelvis, also suggesting right-sided process.
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Fig. 1D —25-year-old woman with acute pelvic pain. Axial
contrast-enhanced CT images show midline fluid-attenuation mass
(asterisk) with progressive narrowing and focal beak sign
(arrow, D) centered in ipsilateral adnexa within lower right
hemipelvis, representing dilated, torsed right fallopian tube. Portion of tube
opposite point of torsion (arrows, C) is seen and is dilated
to lesser degree. Small amount of free fluid (arrowheads, C)
is present within right hemipelvis, also suggesting right-sided process.
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Laparoscopy (Figs. 1E and
1F) showed a dilated, torsed,
and necrotic right fallopian tube that was tense and darkened in appearance,
measuring 8 x 10 cm. The ovaries were normal in appearance. Slight
erythema and dilation of the left fallopian tube was also noted. Omental
adhesions were present in the right lower quadrant. Right salpingectomy was
performed. The patient was started empirically on doxycycline for presumed
pelvic inflammatory disease and was discharged to her home in stable condition
on postoperative day 1. Endocervical cultures were ultimately positive for
Chlamydia trachomatis.
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Fig. 1E —25-year-old woman with acute pelvic pain. Laparoscopic
photographs show right adnexa in situ (E) and after reflection of
fallopian tube (F). Markedly dilated right fallopian tube that appears
very dusky and ischemic (black arrows) on one side of point of
torsion (curved arrows) and less so opposite torsion (straight
white arrows) can be clearly seen in both images. After reflection of
tube, normal right ovary (arrowheads, F) is visualized.
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Fig. 1F —25-year-old woman with acute pelvic pain. Laparoscopic
photographs show right adnexa in situ (E) and after reflection of
fallopian tube (F). Markedly dilated right fallopian tube that appears
very dusky and ischemic (black arrows) on one side of point of
torsion (curved arrows) and less so opposite torsion (straight
white arrows) can be clearly seen in both images. After reflection of
tube, normal right ovary (arrowheads, F) is visualized.
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Discussion
Isolated fallopian tube torsion is a rare cause of lower quadrant pain that
primarily affects adolescents and ovulating women and is rarely seen in
postmenopausal women. The entity was first described by Bland-Sutton in 1890
and has a prevalence of one in 1.5 million women
[1,
2]. Risk factors for isolated
fallopian tube torsion include both intrinsic factors, including pelvic
inflammatory disease, hydrosalpinx, tubal ligation, and tubal neoplasm; and
extrinsic factors such as adhesions, adnexal venous congestion, adjacent
ovarian or paraovarian masses, uterine masses, gravid uterus, and trauma
[3]. Our patient did not have
any obvious risk factors for torsion at the time of presentation but
ultimately was shown to have pelvic inflammatory disease with hydrosalpinx,
resulting from infection with C. trachomatis.
Patients present with a sudden onset of lower quadrant pain that can be
constant and dull or paroxysmal and sharp, radiating to the thigh or groin.
Presenting signs and symptoms also include nausea and vomiting, peritoneal
signs, and a discrete adnexal mass
[1]. Clinically, differential
diagnostic considerations include ovarian torsion, rupture of the ovarian
follicle (mittelschmerz) or cyst, appendicitis, ectopic pregnancy, pelvic
inflammatory disease, intestinal obstruction or perforation, urolithiasis, and
cystitis [1]. Complications
from tubal torsion include fallopian tube necrosis and gangrenous
transformation, leading to an increased risk for superinfection and
peritonitis [1]. Local necrosis
can also result in irreversible damage to the ipsilateral ovary
[4]. Treatment options include
surgical detorsion, salpingotomy, and salpingectomy depending on the stage of
intervention and presence of complications.
A sequential mechanism of action has been proposed that invokes the
mechanical obstruction of adnexal veins and lymphatics, leading to pelvic
congestion and edema, enlargement of the fimbrial end, and subsequent partial
to complete torsion of the involved tube
[5]. Vascular supply to the
fallopian tubes and ovaries comes from both ovarian and uterine vessels,
resulting in the possibility of isolated tubal torsion without vascular
compromise of the ovary. Tubal torsion more commonly affects the right side,
possibly because of partial immobilization of the left tube by its proximity
to the sigmoid mesentery and because right lower quadrant pain is more often
surgically explored secondary to the concern for appendicitis
[6].
Reported sonographic findings include a normal-appearing uterus and ovaries
with normal flow, free fluid, a dilated tube with thickened, echogenic walls;
and internal debris or a convoluted echogenic mass thought to represent a
thickened, torsed tube [4,
7]. High impedance or reversal
or absence of vascular flow in the tube has also been reported
[8], although in practice,
confident spectral Doppler analysis of the tubal wall may be difficult. The
cystic mass seen on sonography in this case represented the displaced,
enlarged torsed right fallopian tube that obscured the left ovary and mimicked
a cystic left adnexal mass. The beaked appearance of this structure with the
vertex centered in the right adnexa is an interesting finding that may have
been a clue to the presence of torsion and its right-rather than left-sided
origin.
Reported CT findings of isolated tubal torsion include an adnexal mass, a
twisted appearance to the fallopian tube, dilated tube greater than 15 mm, a
thickened and enhancing tubal wall, and luminal CT attenuation greater than 50
H consistent with hemorrhage. Secondary signs include free intrapelvic fluid,
peritubular fat stranding, enhancement and thickening of the broad ligament,
and regional ileus [4].
Although ovarian torsion with associated tubal torsion is far more common
than isolated tubal torsion, the imaging diagnosis of an isolated tubal
torsion is far more difficult because of the lack of specific findings. In
practice, patients with this entity are most likely to be referred for
sonography to exclude the diagnosis of ovarian torsion. Although rare, it is
important to recognize the possibility of this diagnosis in the setting of
hydrosalpinx with a sonographically normal ovary in a patient with acute pain,
as delay in diagnosis and treatment may result in increased morbidity. The
imaging findings in this case suggest that a beak sign at the site of torsion
similar to that seen in closed-loop bowel obstructions or volvulus may be
helpful in identifying this entity, although the sensitivity and specificity
of this finding for fallopian tube torsion are unknown. Recognition of this
condition and prompt intervention increase the likelihood of tubal-sparing
surgery and preservation of fertility.
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Introduction
Case Report
