60. Twists and Turns: Paratubal Cysts and Bilateral Fallopian tube Torsion in Adolescents

Abstract

<h3>Background</h3> Fallopian tube torsion secondary to paratubal cysts is a rare presentation of abdominal pain within pediatrics. Abdominal pain is the primary symptom, which may mimic other common pediatric pathologies such as appendicitis. This case highlights the importance of early clinical suspicion to preserve future fertility. <h3>Case</h3> A 10-year-old post-pubertal female presented to an emergency room with intermittent, sharp, right lower quadrant abdominal and flank pain for 24 hours. Imaging suggested possible tubal cysts. She was transferred to a regional children's hospital for advanced care. Upon arrival, her pain was improving. She denied nausea, vomiting, fever, vaginal bleeding, or discharge. On exam, her vitals were stable, and her abdomen was nontender to palpation. No genital exam was performed. Her hemoglobin was 11.7 and her white blood cell (WBC) count was 11.8. Urine microscopy was unremarkable. Gonorrhea and chlamydia PCR and cultures were negative. An abdominal sonography at the children's hospital revealed normal sonographic appearance of the uterus and bilateral ovaries with internal color Doppler flow. A prominent dilated tortuous tubular structure, most compatible with hydrosalpinx. CT abdomen with contrast from an outside hospital initially read as a 5 × 3.2 cm right ovarian cyst. An over-read of the same images by a radiologist at the children's hospital suggested a right-sided hydrosalpinx measuring 8.8 × 7.9 × 6.1 cm in addition to the right ovarian cyst. A diagnostic laparoscopy was performed to drain and possibly excise the suspected ovarian cysts. Upon initial inspection, the left fallopian tube had undergone one complete rotation and contained a 5 × 5 cm paratubal cyst with 30 cc of clear aspirate. The right fallopian tube appeared to have undergone three complete rotations with a similarly sized paratubal cyst. Both the left and right fallopian tubes were detorsed. Following detorsion, the right fallopian tube appeared hemorrhagic and necrotic from the mid-portion of the tube through the fimbria. The ovaries appeared normal bilaterally and no free fluid in the pelvis was noted. A right salpingectomy was performed to remove the necrotic tissue. Histopathology of the right fallopian tube revealed hemorrhage and necrosis with non-neoplastic cystic contents. The postoperative period was uneventful, and the patient was discharged home after surgery. <h3>Comments</h3> Current imaging modalities remain non-specific in diagnosis of tubal torsions, resulting in laparoscopy as the gold standard for definitive diagnosis. High clinical suspicion and early surgical intervention are necessary to preserve future fertility of these young women.