British Journal of Radiology (2004) 77, 784-786
© 2004 British Institute of Radiology
doi: 10.1259/bjr/36288287
Isolated torsion of the hydrosalpinx: a rare presentation
R Shukla, MBBS, DNB (Radiodiagnosis)
Aashlok Hospital, 25-A, Block AB, Community Centre, Safdurjung Enclave, New Delhi-29, India
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Abstract
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Isolated torsion of the Fallopian tube is a rare occurrence, which generally presents in the reproductive age group. It is difficult to diagnose on imaging and the diagnosis is established after laparoscopy. This report describes an unusual presentation of an uncommon condition in a perimenopausal 48-year-old woman who presented with lower abdominal discomfort. The clinical and imaging features led to a suspicion of ovarian neoplasm. Diagnostic laparoscopy revealed torsion of a left sided hydrosalpinx with benign serous cystadenoma of the left ovary. Torsion of the Fallopian tube is a rare event in the perimenopausal age group. It should however be included in the differential diagnosis of lower abdominal pain and recognition of imaging features may allow early surgical intervention.
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Introduction
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Isolated torsion of the Fallopian tube is an uncommon cause of acute low abdominal pain. The reported incidence is 1 in 1 500 000 women [1]. It was originally described by Bland-Sutton in 1890 [2]. The lack of pathognomonic symptoms, clinical findings on physical examination and specific imaging or laboratory characteristics make this entity difficult to diagnose pre-operatively, which can cause surgical intervention to be postponed. In the past, surgical repair was performed at laparotomy. The introduction of laparoscopy for routine use in gynaecology has changed the approach to both the diagnosis and treatment of Fallopian tube torsion.
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Case report
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A 48-year-old perimenopausal woman presented with a 2-week history of lower abdominal pain and discomfort. Progressive constipation was noted since the onset of pelvic symptoms.
She had been medically treated for ileocaecal tuberculosis 20 years ago. Her obstetric history was unremarkable, with no history of tubal sterilization.
On examination, she was afebrile and normotensive. Palpation revealed deep tenderness in the left iliac fossa. Per vaginal examination revealed a tense mass in the left adenexa. Her blood counts and erythrocyte sedimentation rate were normal. Ultrasound revealed a convoluted cystic mass in the left adenexal region with intervening soft tissue. Doppler evaluation revealed high impedance flow in the left adenexal soft tissue (Figures 1 and 2
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CT scan was carried out after administration of oral and intravenous non-ionic contrast medium. A complex cystic mass was seen in the left adenexal region extending into the pouch of Douglas. The left ovary could not be identified separately (Figure 3). The soft tissue component of the mass appeared to cause luminal narrowing of the sigmoid colon. The perilesional fat planes were intact. The diagnosis of a complex left adenexal lesion of ovarian origin was made. In view of the patient's age and sigmoid compression the differential diagnosis included a malignant neoplasm and an inflammatory mass due to tuberculosis.
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Figure 3. Contrast enhanced CT scan showing a complex cystic lesion in the left adenexa extending into the rectouterine recess.
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Serum markers for ovarian malignancy were done at this stage and found to be within normal limits. A diagnostic laparoscopy was then performed, which revealed a dusky blue twisted left hydrosalpinx with a left ovarian cyst. No ovarian torsion was present. The adenexal fat planes were clean with no evidence of endometriosis, pelvic inflammatory disease or tuberculosis.
Histopathological examination revealed the ovarian lesion to be a benign serous cystadenoma. Tubal dilatation was present with epithelial flattening and foci of haemorrhage within the wall.
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Discussion
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The exact cause of Fallopian tube torsion is unknown and various theories have been postulated. Regad surveyed 201 cases of fallopian tube torsion [3] and found a normal appearance in only 24%.
Proposed aetiologies [4–25] for fallopian tube torsion can be classified as:
- anatomical abnormalities (long mesosalpinx, tubal abnormalities, haematosalpinx, hydrosalpinx, hydatids of Morgagni);
- physiological abnormalities (abnormal peristalsis or hypermotility of tube, tubal spasm and intestinal peristalsis);
- haemodynamic abnormalities (venous congestion in the mesosalpinx);
- Sellheim theory (sudden body position changes);
- trauma, previous surgery or disease (tubal ligation, pelvic inflammatory disease);
- gravid uterus.
Many reports indicate that torsion of the Fallopian tube is more common on the right side than on the left [17–23]. This may be due to the presence of the sigmoid colon on the left side or to the slow venous flow on the right side, which may result in congestion. The other reason is that more cases of right sided pain are operated because of the suspicion of appendicitis, whereas left sided cases may be missed or resolve spontaneously.
Only sporadic cases of Fallopian tube torsion are reported each year. It rarely occurs before menarche or during menopause [14, 16, 26]. This dispersion of frequencies is apparently because most risk factors for tubal torsion occur mainly in the reproductive age group.
The most common presenting symptom is pain, which begins in the lower abdomen or pelvis on the affected side but may radiate to the flank or thigh [19–23]. The onset of pain is sudden and cramp-like and may be intermittent [19, 21]. Other associated symptoms include nausea, vomiting, bowel and bladder complaints and scant uterine bleeding [19–23]. Temperature, white blood cell count and erythrocyte sedimentation rate may be normal or slightly elevated.
Imaging findings in torsion of the Fallopian tube are non-specific and clinical correlation is very important.
There have been reports of using ultrasound in the diagnosis of twisted Fallopian tube. The ultrasound appearance is that of an elongated, convoluted cystic mass, tapering as it nears the uterine cornu and demonstration of the ipsilateral ovary separate from the mass. On Doppler evaluation, the finding of high impedance or absence of flow in a tubular structure, especially with a history of tubal ligation can be indicative of diagnosis [23, 27, 28].
This case was unusual in that the presentation was on the left side, and in the perimenopausal age group, making it a rare presentation of a rare entity.
Pre-operative diagnosis of twisted Fallopian tube has not been possible due to the physical findings associated with other common diseases and non-specificity of the imaging findings – a tenet that held true in this case as well. The ovarian cystadenoma, closely abutting the oedematous, twisted and dilated Fallopian tube mimicked an ovarian lesion clinically.
The differential diagnosis of Fallopian tube torsion includes acute appendicitis, ectopic pregnancy, pelvic inflammatory disease, twisted ovarian cyst and degenerative leiomyoma [29, 30].
The management is laparoscopic adenexal detorsion in the reproductive age group and complete resection when the tissue is gangrenous, there is tubal or ovarian neoplasm or the woman has completed her family [23, 30].
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Conclusion
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Fallopian tube torsion, though uncommon, should be included in the differential diagnosis of acute lower abdominal pain in women. The lack of data and non-specificity of imaging findings lead to a retrospective diagnosis of the condition, usually after diagnostic laparoscopy, which remains the reference standard in diagnosis and treatment.
Received for publication July 31, 2003.
Revision received November 18, 2003.
Accepted for publication December 23, 2003.
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Abstract
Introduction
