Isolated torsion of the Fallopian tube is a
rare event. The reported incidence is 1 in 1500000 women.1 The condition more commonly involves the right side.2-8 The clinical and imaging findings are often nonspecific and this entity is difficult to diagnose preoperatively and this can lead to delay in instituting the correct management.
A 35 yr old, nulligravida staff nurse attended the Accidents and Emergency department of our hospital with history of acute left lower abdominal pain. The pain was of cramping type, intermittent with sharp exacerbation. The pain did not radiate to the thigh or groin. It was worse on movement. There was no history of nausea or vomiting, no per vaginal bleeding or temperature. There was no significant past history. She did not have any urinary or bowel symptoms. Urine pregnancy test was negative and urine analysis was normal.
On examination her temperature was 37 degrees Celsius, pulse was 72 beats per minute and blood pressure was 130/80 mm of Hg. Her chest was clear, abdominal examination showed supra pubic and left iliac fossa tenderness, there was guarding and signs of peritonism. Full blood count, CRP and abdominal X-ray were normal. She was assessed by the surgeons and treated with IV therapy and analgesia. An ultrasound of the pelvis was done which revealed – uterus 9.4 cms, ET – 10 mm, right ovary 3.2 cm X 2.9 cm X 2.9 cm, the left ovary was enlarged 7.39 cm X 3.7 cm X 5.3 cm and cystic with fine internal echoes suggestive of possible haemorrhagic cyst.
The Gynaecology team then assessed the patient. She was still in pain and had signs of peritonism; hence CA125 was requested and swabs done. After discussion with the consultant she was consented for laparoscopy with ovarian cystectomy / oophorectomy +/- laparotomy. CA125 was 25i.u.
Laparoscopic findings included (Figs. 1 and 2) :
Fig. 1 : Shows laparoscopic findings –uterus with left
Fig. 2 : Shows uterus with hydrosalpinx during
Leftsided large hydrosalpinx 8-9 cms, torted with three twists, dark purple in colour and necrotic.
- Right tube normal except at the terminal end had a small hydrosalpinx.
- Both ovaries and uterus were normal. Few filmy large bowel adhesions on left pelvic wall. There were features of chronic pelvic inflammatory disease.
Left hydrosalpinx was untwisted and salpingectomy was performed and right hydrosalpinx was incised and drained. Post operative course was uneventful.
Torsion of fallopian tube is a rare event. It was originally described by Bland-Sutton in 1890.9 A survey of 201 cases of Fallopian tube torsion by Regad found a normal appearance in only 24% of the cases.10 The exact cause of a torted hydrosalpinx is not known. Many aetiologies have been proposed, these include; anatomical abnormalities (long mesosalpinx, tubal abnormalities etc.), physiological abnormalities (abnormal peristalsis, tubal spasm and intestinal peristalsis), haemodynamic abnormalities, Sellheim theory (sudden body position changes), trauma, previous surgery or disease and a gravid uterus.2-8,11-23
The commonest presenting symptom is pain, which begins in the lower abdomen or pelvis and may radiate to the flank or thigh, onset is usually sudden and is cramp like and intermittent.4-8 Other associated symptoms are nausea, vomiting, bowel or bladder complains and per vaginal bleeding.4-8 The body temperature and blood count may be normal or elevated and pelvic examination may reveal adnexal mass with cervical tenderness. Our case presented with abdominal pain and symptoms suggestive of peritonism.
Because these symptoms and signs and physical findings are associated with other common conditions the diagnosis is often established at surgery or laparoscopy. The differential diagnosis includes ectopic pregnancy, pelvic inflammatory disease, torted ovarian cyst or bleeding corpus luteal cyst, renal colic or appendicitis if on the right side.24,25 In our case the diagnosis before surgery was a torted ovarian cyst.
The management of this condition consists of early surgery, salpingectomy by laparoscopic or open route is the usual treatment. However, if twisting is incomplete or recent then untwisting and salvaging the tube maybe an option.
Although torsion of hydrosalpinx is uncommon it should be included in the differential diagnosis of pelvic pain. Early surgical intervention is the treatment of choice.
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FLYING IN THE FACE OF DANGER
In this week’s issue of The Lancet, AJM Schreijer and colleagues present results of their study, designed to identify whether flying per se leads to a hypercoagulable state. Hans Stricker welcomes the study’s results, but cautions that “medical prevention of deep vein thrombosis should be limited to persons at risk, such as those with a history of venous thromboembolism, active cancer, or recent major surgery or minor surgery of the lower extremities.
Lancet, 2006; 792, 832.