Computed Tomography Appearance of the “Whirlpool Sign” in Ovarian Torsion

Case Presentation: A 28-year-old female presented to the emergency department complaining of right lower abdominal pain. A contrast-enhanced computed tomography (CT) was done, which showed a 15-centimeter right adnexal cyst with adjacent “whirlpool sign” concerning for right ovarian torsion. Transvaginal pelvic ultrasound (US) revealed a hemorrhagic cyst in the right adnexa, with duplex Doppler identifying arterial and venous flow in both ovaries. Laparoscopic surgery confirmed right ovarian torsion with an attached cystic mass, and a right salpingo-oophorectomy was performed given the mass was suspicious for malignancy. Discussion: Ultrasound is the test of choice for diagnosis of torsion due to its ability to evaluate anatomy and perfusion. When ovarian pathology is on the patient’s right, appendicitis is high in the differential diagnosis, and CT may be obtained first. Here we describe a case where CT first accurately diagnosed ovarian torsion by demonstrating the whirlpool sign, despite an US that showed arterial flow to the ovary. Future studies should determine whether CT alone is sufficient to diagnose or exclude ovarian torsion.

TP9.2.5Routine ultrasound in paediatric appendicitis is highly accurate and substantially reduces negative appendicectomy rate

Aims Our centre routinely uses ultrasound in adults to confirm diagnosis of appendicitis. This study investigated its use in the diagnosis of suspected appendicitis in children and its impact on management. Methods Retrospective cohort study of children (5-16 years) managed by general surgeons with suspected appendicitis during 2019. Primary outcomes were ultrasound use. Secondary outcomes were diagnosis, length of stay, complications and negative appendicectomy rate. Results A total of 193 children were admitted with suspected appendicitis. The majority underwent an ultrasound scan (169/193 [88%]) which identified an inflammed appendix or secondary-inflammation in nearly all cases of appendicitis (65/71 [91%] and 5/71 [7%] respectively). A normal appendix was identified in more than half of children not diagnosed with appendicitis (53/95 [56%]), with the rest showing an ovarian pathology (3/95 [3%]) or normal scan (39/95 [41%]). Ultrasound had high sensitivity (92% [CI 83-97%]) and specificity (100% [CI 96-100%]) for appendicitis. The majority of children diagnosed with appendicitis were treated with laparoscopic appendicectomy (75/85 [88%]) and a minority medically-managed (10/75 [12%]). One appendix mass was medically-managed, and two Meckels Diverticulitis underwent a laparoscopic small bowel resection. Negative appendicectomy rate was extremely low (2/77 [2.5%]). Post-operative complication rate was low (6%). Median length of stay was short for appendicitis and all other diagnoses (2days [IQR 2.2] and 1day [IQR 0] respectively). Discussion The majority of children with suspected appendicitis underwent pre-operative ultrasound, which was highly sensitive and specific for appendicitis. Negative appendicectomy rate was extremely low, and likely related to routine pre-operative imaging.

Influence of the diet's structure on the occurrence of the main gynecological pathologies in the sakhalin population of holstein cows

It was established that the level of metabolic energy and the content of raw fiber in diets significantly affects the milk productivity and the occurrence of reproductive pathologies of cows. With a high level of crude fiber and a lack of metabolic energy in the diet, 12.5 % of cows in the herd were diagnosed with persistent ovarian yellow body. Yellow bodies in the ovaries, as shown by surveys, were most often found 25-30 days after delivery or within the same period of time after infertile insemination, as well as in more distant terms. 23 % of sick cows have a diagnosis "ovarian hypofunction", with impaired growth, development, maturation and timely bursting of the follicles. In some cases, ovarian hypofunction occurred as a result of abnormal labor, untimely start-up and physiological old age of cows. In addition to ovarian pathology, cases of pathological processes in the uterus also led to infertility. Endometritis, as a rule, occurred with inflammation of the uterine mucosa (endometrium). This pathology usually occurred in cases of infection, injuries of the uterine mucosa during pathological childbirth, and retention of the afterbirth. With a low level of raw fiber in the diet and a high content of metabolic energy, the most common cows' pathologies were gynecological diseases in 28 heads (23.3 %). Pathological processes in the ovaries with a high level of metabolic energy in the diet almost completely disappear. Most often, endometritis was diagnosed in sick animals - 98.4 %, associated with infection of the genitals and birth injuries. Studies have shown that blood metabolites, body reserves, and the effectiveness of feeding dairy cows depend on the pH of the environment that occurs when feeding different types of diets. One of the conditions for active fermentation of the substrate is the optimal amount of raw fiber. Pathological processes in the ovaries with a high level of metabolic energy in the diet almost completely disappear.

Torsion hematosalpinx concurrent with acute appendicitis

Isolated fallopian tube torsion is very rare which is reported to be 1 in 1.5 million women. Fallopian tube torsion is commonly associated with hydrosalpinx, hematosalpinx or paratubal cysts such as hydatids of Morgagni. Fallopian tube torsion generally presents a diagnostic dilemma because symptoms and signs mimics ovarian torsion such as acute lower abdominal pain, vomiting, tenderness on palpation but ultrasound may show normal ipsilateral ovary. Right sided adnexal torsion may be difficult to differentiate from acute appendicitis clinically. In such cases ultrasound is helpful but diagnostic laparoscopy is gold standard. We encountered a rare case of torsion hematosalpinx concurrent with acute appendicitis. Patient was presented with acute onset severe lower abdominal pain associated with vomiting and tenderness in right iliac fossa. It was diagnosed as acute tip appendicitis and right adnexal cystic mass either hydrosalpinx/hematosalpinx in ultrasonography. Laparoscopy was done and it was found to be right sided torsion hematosalpinx along with inflamed tip of appendix. Right sided salpingectomy and appendicectomy was done laparoscopically. Fallopian tube torsion should be suspected and diagnostic laparoscopy should be considered in cases of acute onset lower abdominal pain in which ovarian pathology was not found in ultrasonography, that helps in earlier intervention and even in early cases fallopian tube can be salvaged.

19 10 Years of Tertiary Paediatric Centre Experience of Females Undergoing Surgery for Ovarian Torsions

Aim Review role and accuracy of imaging, and subsequent management, of patients with ovarian torsion managed at a tertiary paediatric centre. Method Retrospective review of notes for patients undergoing surgery for ovarian torsion over 10 years (2010-2019). Results 23 patients underwent surgery for ovarian torsion (one excluded due to lack of data). Median age 12 years[range 1-15]. 18/22 patients underwent imaging; 15/18 had USS, 12/15(80%) were diagnostic for ovarian torsion. 3/15 showed ovarian pathology prompting further imaging/surgery. 2/22 had initial MRI, 1 diagnostic for torsion. Time from symptom onset to surgery was assessed, data was incomplete for 4 patients. 10 patients were referred from ED/primary care; 5(50%) underwent theatre within 12 hours, 3(30%) 12-12hours and 2(20%) >24hours. 8 patients were referred from external hospitals; 2(25%) underwent theatre within 12 hours, 4(50%) 12-12hours and 2(25%) >24hours. Those having surgery>24 hours from symptom onset were awaiting imaging or had suspected other pathology. 4/22 underwent oophorectomy (open:laparoscopic=3:1) and 18/22 had detorsion +/- cyst aspiration/excision (open:laparoscopic:converted=2:15:1). Follow up imaging was performed in 13/18 patients who underwent detorsion and 2/5 who underwent oophorectomy. Of 3 patients undergoing oopherectomy who did not have follow up; 2 had benign cysts and 1 had a simple tubo-ovarian torsion. Conclusions We advocate early USS in females with presentation concerning for ovarian torsion, though a high index of suspicion is often required owing to non-specific symptoms. Imaging and transfer should be performed promptly to prevent delays in surgical management.

Missed opportunities for ovarian salvage in children: an 8-year review of surgically managed ovarian lesions at a tertiary pediatric surgery centre

Introduction The aetiology and management of ovarian pathology in children differs between antenatal and postnatal lesions. However, all lesions may present acutely due to adnexal torsion. In this setting, opportunities to preserve fertility with ovary-sparing surgery (OSS) may be missed. Some studies suggest that pediatric and adolescent gynaecology (PAG) input in care is associated with OSS. Methods A retrospective cohort study of children undergoing surgery for ovarian pathology at a tertiary pediatric surgery centre over an 8-year period (2011–2018). Patient factors, lesion characteristics and PAG involvement were examined for association with OSS using multivariate logistic regression. Results Thirty-five patients with ovarian pathology managed surgically were included. Ten were infants with lesions detected antenatally; all were managed by pediatric surgeons (PS) alone at median age 2 weeks (1 day–25 weeks). Twenty-five patients presented postnatally at median age 11 (0.75–15) years. In total, there were 16 cases of adnexal torsion, each managed primarily by PS. Twelve underwent oophorectomy and six (50%) of these cases had viable ovarian tissue on histology. Furthermore, two infants with large simple cysts were similarly managed by unnecessary oophorectomy based on histology. Overall rate of OSS was 46% and PAG involvement was the only factor associated with ovarian salvage. Conclusion Differences in surgical management between PAGs and PS may be attributable to the different patient populations they serve. We recommend improving the knowledge of PS trainees in OSS approaches for adnexal torsion and large benign lesions.

Leydigcelhyperplasie: een zeldzame oorzaak van hyperandrogenisme bij een menopauzale vrouw

Leydig cell hyperplasia: an atypical cause of postmenopausal hyperandrogenism We present a case of a 64-year old postmenopausal patient with new onset hirsutism, acne and clitoromegaly. Her medical history includes a non-secreting adrenal incidentaloma. Biochemical evaluation withheld an elevated testosterone with normal dehydroepiandrosterone sulphate (DHEAS). Other adrenal biochemical tests were normal and adrenal imaging was unaltered. Imaging of the ovaries was unremarkable. Due to the normal DHEAS, ovarian etiology was suspected, for which a bilateral oophorectomy was performed. Pathological examination showed bilateral Leydig cell hyperplasia, a benign though rare cause of postmenopausal hyperandrogenism. Postmenopausal hyperandrogenism is caused by of a group of gynaecological and endocrinological disorders. In case of rapid onset and severe symptoms of hirsutism or virilization an androgen-secreting neoplastic disorder should be suspected. Normal DHEAS is suggestive for an ovarian etiology. Imaging is necessary to differentiate between adrenal and ovarian causes, though normal imaging of the ovaries does not rule out ovarian pathology. Definitive diagnosis is often based on pathological examination after oophorectomy.

Soluble forms of immune checkpoints in ovarian cancer

The data of a complex immunoassay comparative study of the content of soluble forms of sPD-1, sPD-L1, sNKG2D, sNKG2DL1, sB7-H3 and sHLA-G in the blood plasma of 75 patients with epithelial ovarian cancer and 20 healthy donors of the control group are presented. The diagnostic significance of the studied proteins was determined. The study showed that the profile of soluble immunity checkpoints differs when malignant ovarian pathology occurs. There was a statistically significant decrease in the content of sPD-L1, sNKG2DL1, sB7-H3, and sHLA-G in the blood plasma of patients compared with the control group. Differences were found in the content of the studied markers depending on the histological type of tumors. Correlations between the soluble forms of some of the studied proteins are shown, indicating the presence of independent mechanisms of immune regulation in ovarian cancer, which may explain the insufficient effectiveness of the existing immunotherapy for this type of tumor. The results obtained will undoubtedly facilitate the development of new effective methods for the diagnostics and therapy of ovarian cancer.

GIANT OVARIAN SEROUS CYSTOADENOMA IN PATIENT AFFECTED BY COVID19: EXPERIENCE OF AN EXCEPTIONAL CASE

In the last 40 years, humanity has been affected by three major pandemics that have claimed many deaths: the increase in the incidence and prevalence rates of chronic non-communicable diseases, the pandemic of the immunodeciency virus disease human-AIDS (HIV / AIDS) and currently the pandemic caused by covid-19. Covid-19 is an emerging viral infectious disease, which has contributed to increasing mortality from chronic diseases in a very short time. Epidemics of unknown emerging diseases such as covid-19 put to the test not only the technical and human capacity of health professionals who directly care for the sick, but, and above all, that of health systems and society usually. For an adequate understanding of this phenomenon, they must be approached with a general approach that integrates many elements that, otherwise, can only give a partial vision of the matter. Due to the aforementioned, we consider it necessary to present this clinical case, based on ovarian pathology of a positive patient for the new coronovarirus and its subsequent interdisciplinary management. Giant ovarian cysts are considered this way when they weigh more than 12 kilos. They are a rare entity today. By denition, a cystic growth of the ovary must be at least 3 cm in diameter to be called a cyst. In the 1970s and 1980s, 20 cases of cysts greater than 20 kg were reported in the world literature. Ovarian tumors are not as common as those of the uterus and breast. They constitute the third group of benign and malignant tumors in women. Ovarian serous cystadenoma arises from the supercial (coelomic) epithelium, made up of cystic areas. There are macroscopically small tumors and massive tumors that occupy the entire pelvis and even the abdominal cavity. Until now, no literature has been found that gives us information on ovarian pathology during the course of the pandemic that we are now experiencing; reason for which this clinical case is presented. Objective: Describe the adnexal pathology associated with covid-19 infection. Design: Prospective, observational in a single center. Methodology: This is a systematic review of adnexal pathology in a patient affected by the new coronavirus (Covid-19); emphasizing its clinical characteristics and its short-term complications. The information and images obtained belong to the medical staff in charge of the case, whose reinforcements are provided by the Excel, Word and JPG statistical package.

Clinical profile of patients undergoing abdominal hysterectomy at a medical college in Nepal

Background: Hysterectomy, removal of the uterus, is one of the most frequently performed gynecological surgeries, with approximately six hundred thousand women undergoing this procedure annually in the United States. Indications of hysterectomy vary from benign conditions to malignancies of the genital tract. Hysterectomy is also associated with intraoperative and postoperative complications. Aims and Objectives: The aim of the current study was to analyze indications, complications, duration of hospital stay, blood loss during surgery and correlation of preoperative diagnosis with final histopathology report of all abdominal hysterectomies performed at a teaching hospital. Materials and Methods: This study involved all patients who underwent abdominal hysterectomy at Manipal Teaching Hospital, Pokhara, Nepal over a span of 18 months (from 1st January, 2018 to 31st June, 2019). It was a retrospective study. All the patients undergoing abdominal hysterectomy during the study period were taken without any exclusion criteria. Results: There were 101 cases of abdominal hysterectomies performed during the study period. Majority of the patients were from urban areas than rural areas (67.3% vs 32.7%). Mean age of patients undergoing abdominal hysterectomy was 45.48 years with 2 standard deviation (SD) of 8.75. The youngest patient aged 26 years and the eldest aged 67 years. Mean parity was 2.50 with 2 SD of 1.197. Majority of the patients presented with pain abdomen (49.5%) and menstrual disorders (38.6%). The most common indication for hysterectomy was uterine fibroids (51.5%) followed by ovarian pathology (16.8%). The histopathology report of the patients showed that majority of the patients had fibroid uterus (51.4%) and ovarian pathology (16.8%). Mean intraoperative blood loss was 239.60 ml with 2 SD of 197.144. Mean hospital stay was: 7.29 days with 2SD of 3.144. The maximum hospital stay was 18 days in two patients and most patients had hospital stay between 5 to 8 days. The commonest complication was surgical site infection (9.9%) needing resuturing followed by urinary tract infection (7.9%). Conclusion: Wide spectrums of lesions were encountered during the surgery. The preoperative diagnosis, duration of hospital stay, average blood loss, surgical complications and histopathological reports correlated with various others studies.