A 14yr old girl presents via ambulance with severe left iliac fossa pain. She reports that it started that earlier that afternoon, as a mild discomfort in her left iliac fossa that radiated into her left flank. This was associated with nausea and loss of appetite. She decided to go to bed early but was woken a short time later by a sudden increase in her pain associated with vomiting.
Her worried parents called an ambulance and she was treated with 10mg IV morphine during transfer to hospital. Despite this, she reports that her pain is still 9/10. She is currently menstruating and is not sexually active.
On examination she is pale and looks in pain. She has normal observations. Her abdomen is soft but very tender in her left iliac fossa.
Given the significance of her pain, a diagnosis of ovarian torsion is considered and she is referred urgently to the Gynaecology team, who promptly review and agree with this diagnosis. Whilst making arrangements for theatre, they arrange an urgent ultrasound scan which demonstrates a large cyst on the left ovary with absent venous flow on colour doppler and a small volume of pelvic free fluid.
She is urgently taken to theatre where they discover a torted left ovary secondary to a very large ovarian cyst with a volume of over 500mls. There is no evidence of ovarian necrosis and once detorted, the ovary looks healthy. She recovers well and is discharged from hospital the following day.
1) Sudden onset, severe lower abdominal pain in a teenage girl - think Ovarian torsion
Ovarian torsion typically presents with severe lower abdominal or pelvic pain, associated with nausea or vomiting. The pain can be intermittent or sustained and the patient often requires significant doses of opiate analgesia.
2) Time = Ovary
Ovarian torsion is a gynaecological emergency - over just a few hours the ovary can infarct and become necrotic secondary to vascular compromise. Refer suspected cases early in order to minimise time to theatre.
3) Ovarian torsion should be a clinical diagnosis, don’t wait for an ultrasound scan
As delays to operative intervention can have devastating consequences, ultrasound scans should only be ordered in consultation with your local gynaecology/surgical team.
NB: Subtle changes have been made to this case to protect patient confidentiality
Dr Danielle Scarfe
Dr Danielle Scarfe