Ovarian Torsion Explained Clearly by MedCram – A BV Exam Question


welcome to MedCram.com and Board
Vitals questions this question comes from our OBGYN and family medicine
question banks a 24 year old female presents to the emergency department
with the acute onset of severe right lower quadrant abdominal pain her
temperature is 98.5 she’s doubled over in pain as had three episodes of
vomiting since the onset of pain two hours ago
there’s no migration of patients pain last menstrual period was two weeks ago
and was normal she denies any recent urinary discomfort or abnormal vaginal
discharge rapid urine pregnancy test is negative
what emergent study should be ordered on this patient to confirm the diagnosis is
it a CT scan of the abdomen and pelvis with contrast, B pelvic ultrasound with
Doppler flow, C urinalysis, D colposcopy, or E, GC
chlamydia probe, well the key here is understanding that this is an OBGYN case, right, this is a 24 year old female, the other thing to notice is that it’s been
2 weeks since the menstrual period so we’re probably dealing with the time of
ovulation, start thinking about a cyst the biggest thing to worry about here of
course is a twisting or a torsion of the ovary causing immediate severe pain so
the thing that you want to look for are things to eliminate obviously a GC
chlamydia probe is not going to be the answer because that doesn’t come on
acutely colposcopy is only going to get you a look up the vagina to the cervix
and you’re not gonna be able to see inside which is where that problem is
urinalysis is going to be helpful in looking at a urinary tract infection but
those do not come on this acutely and so what we’re really looking for here is
the best radiographic imaging to help you with that diagnosis is it a CAT scan
with contrast or is it a pelvic ultrasound with Doppler flow so you have
to realize that a twisting of the ovary is actually gonna impinge or eliminate
flow in both the vein and the artery if it’s complete if it’s partial you’ll
have somewhat a flow in the artery but not in the vein so let’s take a look
a bit more of the anatomy of the ovary so here you can see that the ovary is
very vascular and if you were to have a cyst on it you could see that there
could be some easy twisting and knocking off of these blood vessels to the ovary
which is extremely tender it’s extremely painful and it comes on very quickly and
you know this is what we’re talking about here is that you’ll see an artery
that runs along the ovary and then branches off but you’ll also see
branches of vein come along the same way and so what you can have here is a
twisting of the ovary especially if there’s a cyst that’s growing on the
ovary and what you will see first is a complete occlusion of the vein until you
finally have an occlusion of the artery so it’s possible that if you have no
flow that it’s definitely a positive for ovarian torsion no question about it
however if there is flow it’s still possible that you’ve got some flow but
it’s not completely twisted and so at that point you’re unsure so here if you
were to do an ultrasound with Doppler and you were to have absolutely no flow
you could make the diagnosis of a torsed ovary, a CT scan would be helpful
in looking for a cyst but it would not be as helpful in making a diagnosis of
no flow and therefore B is going to be the right answer

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