A 15-year-old girl is brought to the emergency department with intermittent lower abdominal pain. The patient woke up this morning with intermittent, sharp pain in the left lower quadrant that radiates to the lower back. The pain episodes are associated with nausea and vomiting and spontaneously resolve after a few minutes. She has no nausea or vomiting between episodes and no urinary symptoms, vaginal bleeding, or abnormal vaginal discharge. The patient has no chronic medical conditions and takes no daily medications. Her last menstrual period was 2 weeks ago, and she is not sexually active. Temperature is 37.2 C (99 F), blood pressure is 130/84 mm Hg, pulse is 118/min, and respirations are 20/min. On examination, the patient appears comfortable and has mild tenderness to palpation in the left lower quadrant. Urine pregnancy test is negative. Pelvic ultrasound shows a 5-cm left ovarian mass with normal ovarian arterial and venous blood flow. After the ultrasound, the patient has another episode of severe pain with nausea when walking back to her room from the restroom. On reevaluation, she is in acute distress and has severe, constant tenderness to palpation in the left lower quadrant. Which of the following is the best next step in management of this patient?

Question

A 15-year-old girl is brought to the emergency department with intermittent lower abdominal pain.  The patient woke up this morning with intermittent, sharp pain in the left lower quadrant that radiates to the lower back.  The pain episodes are associated with nausea and vomiting and spontaneously resolve after a few minutes.  She has no nausea or vomiting between episodes and no urinary symptoms, vaginal bleeding, or abnormal vaginal discharge.  The patient has no chronic medical conditions and takes no daily medications.  Her last menstrual period was 2 weeks ago, and she is not sexually active.  Temperature is 37.2 C (99 F), blood pressure is 130/84 mm Hg, pulse is 118/min, and respirations are 20/min.  On examination, the patient appears comfortable and has mild tenderness to palpation in the left lower quadrant.  Urine pregnancy test is negative.  Pelvic ultrasound shows a 5-cm left ovarian mass with normal ovarian arterial and venous blood flow.  After the ultrasound, the patient has another episode of severe pain with nausea when walking back to her room from the restroom.  On reevaluation, she is in acute distress and has severe, constant tenderness to palpation in the left lower quadrant.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d16d_70be_bc81_7b03635935bf_MD0003_00 This patient likely had intermittent partial ovarian torsion that progressed to complete ovarian torsion. Partial ovarian torsion, due to intermittent adnexal rotation around the infundibulopelvic ligament containing the ovarian vessels, causes temporary ovarian vessel occlusion and pelvic pain (from ovarian ischemia). Patients classically have nausea, vomiting, and intermittent pain that self-resolves (ie, no symptoms between episodes) as spontaneous adnexal untwisting allows blood flow to return. Therefore, Doppler ultrasound may show normal ovarian arterial and venous blood flow. Partial ovarian torsion can progress to complete ovarian torsion. Although torsion is less common in the pediatric population, an ovarian mass (as in this patient) increases the risk for complete torsion because the increased adnexal size and density make spontaneous untwisting less likely. Complete torsion, typically triggered by physical activity (eg, walking), presents with severe, constant, unilateral pelvic pain due to ongoing ovarian ischemia. Complete torsion is a clinical diagnosis in patients with the classic symptoms. Management is with diagnostic laparoscopy for manual detorsion of the adnexa and removal of any contributory cysts or masses; oophorectomy may be required if the ovary is necrotic. (Choice A) In young women with an ovarian mass and a classic presentation of ovarian torsion, such as this patient, other etiologies of abdominal pain are unlikely. Due to the emergent nature of ovarian torsion, additional imaging (eg, CT scan of the abdomen and pelvis) is inappropriate because it delays evaluation and treatment. (Choices C and D) NSAIDs and outpatient follow-up are typical management for mild to moderate pelvic pain caused by self-limiting, physiologic processes (eg, mittelschmerz, ruptured simple cyst). Patients who cannot tolerate oral analgesics (eg, nausea/vomiting) may require observation and serial abdominal examinations. (Choice E) Quantitative β-hCG levels are measured for suspected ectopic pregnancies (eg, positive pregnancy test with no intrauterine gestation visualized on ultrasound). This patient's urine pregnancy test (a qualitative test) is negative, making ectopic pregnancy unlikely and quantitative serum β-hCG measurement unnecessary. Educational objective: Partial ovarian torsion typically presents with intermittent, self-resolving episodes of unilateral pelvic pain due to temporary ovarian vessel occlusion. Patients with intermittent partial torsion can suddenly develop complete torsion, which requires diagnostic laparoscopy. References: Ovarian torsion in pediatric patients: a review of eleven years' experience. (http://www.ncbi.nlm.nih.gov/pubmed/27335930) 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 15-Year-Old Girl Is Brought to the Emergency Department with Intermittent