A 19-year-old woman comes to the emergency department due to lower abdominal pain. The pain is intermittent and started this morning during a yoga class. The patient has also vomited twice. She has no chronic medical conditions and takes no daily medications. She is sexually active and uses a copper-containing intrauterine device for contraception. The patient's last menstrual period was 2 weeks ago. Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, and pulse is 104/min. Abdominal examination shows diffuse lower abdominal tenderness, left greater than right, with no rebound or guarding. Pelvic ultrasound reveals a complex left adnexal mass with absent Doppler flow. There is a moderate amount of free fluid in the posterior cul-de-sac of the pelvis. Which of the following is the best next step in management of this patient?

Question

A 19-year-old woman comes to the emergency department due to lower abdominal pain.  The pain is intermittent and started this morning during a yoga class.  The patient has also vomited twice.  She has no chronic medical conditions and takes no daily medications.  She is sexually active and uses a copper-containing intrauterine device for contraception.  The patient's last menstrual period was 2 weeks ago.  Temperature is 36.7 C (98.1 F), blood pressure is 130/80 mm Hg, and pulse is 104/min.  Abdominal examination shows diffuse lower abdominal tenderness, left greater than right, with no rebound or guarding.  Pelvic ultrasound reveals a complex left adnexal mass with absent Doppler flow.  There is a moderate amount of free fluid in the posterior cul-de-sac of the pelvis.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8d3_aaf8_bc81_7d78c9b456c1_MD0003_00 This patient's lower abdominal pain is consistent with ovarian torsion, or rotation of the ovary around the infundibulopelvic ligament, leading to vessel occlusion and ovarian ischemia. Ovarian torsion is commonly precipitated by physical activity, and the initial pain can be colicky in cases of partial torsion (ie, intermittent adnexal twisting and untwisting); however, when progression to complete torsion occurs, patients typically develop severe, unilateral lower abdominal pain with nausea/vomiting. The ovary can become enlarged, edematous, and tender and have associated inflammatory pelvic free fluid. rotation of the ovary Although ovarian torsion is usually diagnosed clinically and confirmed surgically, Doppler ultrasound can support the diagnosis and decision for surgery. Ultrasound classically shows an adnexal mass (ie, the torsed ovary) with absent Doppler blood flow (ie, occluded ovarian vessels), as seen in this patient; it can be normal with partial torsion (due to adnexal untwisting). Management is with emergency laparoscopy for detorsion to prevent ovarian necrosis and its associated complications (eg, chronic pelvic pain, infertility); any contributory adnexal masses are also usually removed. (Choice A) Ovarian torsion can cause elevated CA-125 levels due to release from the ischemic ovary. However, CA-125 levels do not affect torsion management (ie, laparoscopy). In addition, CA-125 levels (classically associated with epithelial ovarian cancer) are not routinely obtained in premenopausal patients because benign conditions can increase CA-125 levels in this population. (Choice B) CT scan of the abdomen and pelvis is indicated if another diagnosis (eg, appendicitis) is suspected. This patient's ultrasound findings are classic for torsion, and surgery cannot be delayed. (Choice C) Culdocentesis can be used to sample and identify peritoneal fluid from the posterior cul-de-sac via vaginal aspiration. It has largely been replaced by ultrasonography, which rapidly and accurately identifies pelvic free fluid and its composition (eg, blood). (Choice E) Methotrexate is a medical treatment for ectopic pregnancy. Although ectopic pregnancies can cause pain and pelvic free fluid, they typically have increased, not absent, Doppler flow due to rapid tissue growth. (Choice F) Needle aspiration may be performed to drain a symptomatic simple ovarian cyst (ie, low risk of malignancy). In contrast, this patient's complex adnexal mass with lack of Doppler flow requires surgery. (Choice G) NSAIDs and observation are appropriate for self-limiting, nonurgent causes of pelvic pain (eg, ruptured simple ovarian cyst). This patient with no ovarian Doppler flow requires surgery. Educational objective: Ovarian torsion presents with lower abdominal pain and ultrasound findings of an adnexal mass with absent Doppler flow. Laparoscopy is required for detorsion of the adnexa and removal of any contributory adnexal masses. References: Adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/29941434) Accuracy of pelvic ultrasound in diagnosing adnexal torsion. (http://www.ncbi.nlm.nih.gov/pubmed/31354994)

A 19-Year-Old Woman Comes to the Emergency Department Due to Lower