Clinical Predictors of Isolated Tubal Torsion: A Case Series

Abstract

A rare cause of adolescent abdominal pain includes isolated tubal torsion (ITT), involving at minimum one complete turn of the fallopian tube around the infundibulopelvic and utero-ovarian ligaments without involving the ipsilateral ovary. The presentation of ITT is nonspecific and only a few previous studies have investigated adolescents. The aim of our study is to describe the presentation and management of ITT in a large case series. Retrospective observational case series of adolescent females aged 3–24, presenting to Children’s Hospital Colorado and diagnosed with ITT based on ICD-9 code between 1/2004 thru 8/2015. Details of the clinical presentation, physical exam, laboratory findings, and surgical diagnosis and treatment were extracted from the medical records of identified cases. Two authors reviewed each case to confirm accuracy of data gathering. A total of 19 cases were included (Table 1). Average age of subjects was 13.3 years old (11-18). In patients with unilateral abdominal pain (n=16), there was 100% correlation with side of adnexal pathology. Ultrasound imaging in 14 of 18 cases (78%) noted abnormal findings ipsilateral to the ITT. A majority of patients were managed with laparoscopy (84%) and detorsion +/-cystectomy (74%). Salpingectomy was more common with history of prolonged pain > 24 hours (RR 5.6, CI 0.7 – 39.0). The most common intraoperative pathology was a paratubal cyst (74%, n= 14). When ultrasound Doppler flow was performed, it was present in 88% (n = 15) of the effected adnexa. ITT was more common on the left side (68%, n= 13). The high occurrence of paratubal cysts may suggest pathologic predisposition for ITT. Providers should have high index of suspicion for ITT when evaluating adolescent abdominal pain, particularly if associated with a paratubal cyst. Classic exam findings of surgical abdomen, leukocytosis or fever and absence of Doppler flow on ultrasound are not always present. Laparoscopy and detorsion are appropriate treatment options for managing ITT.Table 1Clinical presentation, intraoperative findings, and managementClinical PresentationPercent (n = 19)Pain present100% (19)Duration of pain≤ 24 hours53% (10)> 24 hours47% (9)Pain onsetSudden63% (12)Gradual36% (7)Pain severityMild16% (3)Moderate37% (7)Severe47% (9)Nausea68% (13)Vomiting47% (9)Fever ( Temperature ≥ 38.0)11% (2)Tachycardia (Heart rate ≥ 100)32% (6)Abdominal tenderness95% (18)Guarding32% (6)Rebound37% (7)Leukocytosis (WBC ≥ 10)43% (61)Imaging modalityCT57% (11)Ultrasound95% (18)Adnexal mass present on imaging100% (182)Doppler flow present79% (152)TreatmentPercent (n = 19)Surgeon specialtyPediatric gynecology79% (15)Pediatric surgery21% (4)Surgical approachLaparoscopy84% (16)Laparotomy11% (2)Both5% (1)Surgery performedSalpingectomy32% (6)Detorsion5% (1)Detorsion + paratubal cystectomy58% (11)Detorsion + paratubal cyst drained6% (1)Detorsion + drainage of hydrosalpix6% (1)Oophoropexy0% (0)Oophorectomy0% (0)Associated paratubal cyst74% (14)1: 14 cases had preoperative CBC results2: 18 cases had preoperative ultrasound Open table in a new tab