Isolated fallopian tube torsion with preservation of ipsilateral ovary. A case report

Abstract

Isolated fallopian tube torsion (IFTT) is a rare cause of acute lower abdominal pain in women. Its nonspecific clinical presentation makes preoperative diagnosis more challenging. Laparoscopy is the gold standard in diagnosis and treatment.

This is a case of a 25-year-old newly married patient presented to the emergency department with sever acute lower abdominal pain associated with nausea. Clinical physical examination revealed abdominal tenderness. Ultrasound showed a right ovarian cyst measuring 4.5 cm × 4.1 cm with mural nodule, no internal vascularity on color doppler. Laparoscopy was performed where the right fallopian tube was found edematous, darkened red in color. Therefore, isolated fallopian tube torsion was diagnosed and right salpingectomy was performed with preservation of the right ovary. Postoperative recovery was uneventful.

Histopathological examination confirmed necrosis of the excised fallopian tube.

Isolated fallopian tube torsion is a rare yet noteworthy event. Early diagnosis and timely management are crucial for tubal sparing surgery.

Highlights

• •Isolated fallopian tube torsion is a rare event that has been reported to affect women in all age groups and in pregnancy.
• •The clinical presentation of IFTT is usually nonspecific; therefore, the diagnosis is likely to be challenging.
• •Early diagnosis and timely management are crucial for tubal sparing surgery.
• •Laparoscopy is the gold standard in diagnosis and treatment.

1. Introduction

Isolated fallopian tube torsion (IFTT) without involvement of the ipsilateral ovary was first described by Bland-Sutton in 1890 as a rare cause of acute lower abdominal pain in women with an estimated prevalence of 1in 1.5 million women [1]. A suggested causative mechanism resulting in tubal torsion involves the rotation of the tube around its longitudinal axis, leading to mechanical obstruction of adnexal veins and lymphatics, and subsequent pelvic congestion and edema, enlargement of the fimbria, and necrosis of the involved tube. [2]

The clinical presentation of IFTT is usually nonspecific; therefore, the diagnosis is likely to be challenging. Fallopian tube torsion is a gynecological emergency that requires early surgical intervention to preserve the fallopian tube and thus fertility, laparoscopy is the gold standard for establishing diagnosis and treatment [3].

Here we report a case of isolated fallopian tube torsion in a young woman presented with acute lower abdominal pain.

2. Case

A 23-year-old lady, with no significant medical or surgical history presented to the emergency department complaining of sudden onset sever right sided lower abdominal pain, throbbing in nature with an intensity of 9/10. The pain was not associated with fever, chills, abnormal vaginal discharge or significant urinary or bowel symptoms.

The patient was nulliparous, had been married for 4 months, had regular menstrual cycle and her last menstrual period was one week before presentation. She was not using contraception.

On evaluation, her blood pressure was 130/85, Pulse 108 beats/min and Temperature 36.6 °C. Abdominal examination showed significant right lower quadrant tenderness without rebound or guarding.

Laboratory results revealed a negative quantitative BHCG, hemoglobin level of 13 g/dL and white blood cell count of 11.5 × 103 cells/mm3.

Transvaginal ultrasound was performed and showed a normal uterus, the left ovary volume was 4.9 mL, showing multiple follicles and preserved vascularity on spectral waves, the right ovary volume was 9.9 mL, and demonstrated homogenous parenchymal echotexture, with preserved venous flow on spectral waves, however no arterial flow could be detected. A right ovarian cyst measuring 4.5 × 4.1 cm with mural nodule, no internal vascularity on color doppler.

The patient was admitted to the hospital as a case of right ovarian cyst torsion, for which laparoscopy was performed and revealed a dilated, twisted, and necrotic right fallopian tube that was darkened dusky red in color (Fig. 1). The ovaries and left fallopian tube were normal in appearance. Right salpingectomy was performed (Fig. 2).

Fig. 1.

Isolated right fallopian tube torsion.

Fig. 2.

Salpingectomy was done for edematous dusky dark red fallopian tube. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

The patient had uneventful recovery and was discharged home on the second postoperative day and was counselled about her future fertility and contraception.

Histopathological examination of the excised tube confirmed the torsion with blood clots and hemorrhagic necrosis in the wall of the tube.

3. Discussion

Isolated fallopian tube torsion is a rare event that has been reported to affect women in all age groups and in pregnancy. [1] Risk factors for IFTT include pelvic inflammatory disease, adhesions, hydrosalpinx, tubal ligation or neoplasm, adnexal venous congestion, ovarian or paraovarian masses, gravid uterus and trauma [2]. Our patient did not have any obvious risk factor for torsion.

As in our case, torsion of the right tube is more commonly encountered than torsion of the left tube, possibly due to the partial immobilization of the left tube by its proximity to the sigmoid mesentery. In addition, the right lower quadrant pain is more often investigated and surgically explored secondary to the concern for appendicitis [4].

The signs and symptoms of IFTT are non-specific and common to many other conditions, making the correct preoperative diagnosis more challenging. The majority of patients present with acute severe lower abdominal pain, in addition to nausea, vomiting, urinary symptoms and peritoneal signs. [1] The woman in our case report presented to the emergency department with severe lower abdominal pain and nausea, and typical clinical examination finding of abdominal tenderness.

Reported ultrasound findings include a normal appearing uterus and ovaries, a dilated tube with thickened, echogenic walls and internal debris or a convoluted echogenic mass thought to represent a thickened, torsed tube; however, these findings are not definitive in establishing the diagnosis of IFTT. High impedance or absence of vascular flow in the tube has also been report although, confident spectral Doppler analysis of the tubal wall may be difficult [5]. On the other hand, the main sonographic features of ovarian torsion are enlargement of the ovary with peripherally displaced follicles and hyperechoic central stroma as well as pelvic free fluid. Doppler findings in ovarian torsion are widely variable including little or no venous flow, absent arterial flow. [6] In this case report the sonographic findings were enlarged right ovary and a right ovarian cyst with absent arterial blood flow represented the enlarged torsed right fallopian tube.

The recommended management is laparoscopic fallopian tube detorsion if the tube is still viable. If necrotic and gangrenous, laparoscopic salpingectomy is the preferred option [3]. In our patient the fallopian tube was necrotic and darkened dusky red in color; therefore, our management was laparoscopic salpingectomy.

4. Conclusion

Isolated fallopian tube torsion is a rare yet noteworthy event; therefore, it is critical to keep a high index of suspicion for IFTT in all women presenting with acute lower abdominal pain.

Recognition of this condition and timely management increase the likelihood of tubal-sparing surgery and preservation of fertility [7].