21 Year Old female With Complaint Of Severe Right Lower Abdominal Pain

A 21 year old female presents to the emergency department with the complain of severe right lower abdominal pain that started this morning. The pain is 7/10 in intensity and constant in nature. It is exacerbated by movement and does not radiate. It is accompanied by fever, nausea and one episode of vomiting. Her LMP was 4 weeks back and she is sexually active. She has a history of regular periods every 4 weeks lasting for 6 days. She did notice some brownish spotting this morning which she thought was her periods because she was due. She is on birth control pills nowadays. She had a normal vaginal delivery 18 months back. Her past history is not significant for any illnesses or any major surgery.  On examination, she looked pale and was in pain. Her abdomen was tender on palpation more on the right side. On pelvic examination she had severe pain and the cervix and the uterus seemed to be pushed on one side.

 What will be the differential diagnosis on the basis of History and examination?

Differential Diagnosis:

• Pelvic inflammatory disease.
• Torsion of an ovary
• Torsion of the ovarian cyst
• Adnexal torsion
• Acute appendicitis
• Ruptured ectopic pregnancy
• Abortion

 Urine hCG was negative and pregnancy was almost ruled out. She was taken for a transvaginal ultrasound and it shows the following picture;

Sonographic Whirlpool Sign in Ovarian Torsion





Patient was finally diagnosed as a case of Ovarian cyst with Ovarian torsion.

Case Discussion:
Ovarian cysts that become large may cause the ovary to move out of its usual position in the pelvis. This increases the chance of a painful twisting of the ovary called ovarian torsion.
Ovarian torsion is an infrequent but an important cause of lower abdominal pain in women and should always be considered if young women present with an acute lower abdominal pain. The clinical presentation if often non specific sometimes resulting in delay in diagnosis and surgical management. Ovarian torsion classically occurs unilaterally in the pathologically enlarged ovary, and in more than half the cases it involves the presence of an ovarian cyst.

Management: Surgical treatment of ovarian torsion includes laproscopy to uncoil the torsed ovary and sometimes fixing the ovary so as to prevent from twisting again. In severe cases where the blood flow to the ovary has been stopped for longer duration leading to necrosis and death of  ovarian tissue may need a removal of the ovary.