{"paper_id":"32cd8370-5b28-4d9a-bc1d-5a036b55f417","body_text":"WWW.KJOG.ORG 55\nISOLATED TORSION OF BILATERAL FALLOPIAN TUBES \nCOMBINED WITH TUBAL ENDOMETRIOSIS: A CASE REPORT\nSu Yeon Lim, MD, Joon Cheol Park, MD, PhD, Jin Gon Bae, MD, Jong In Kim, MD, PhD, Jeong Ho Rhee, MD, PhD\nDepartment of Obstetrics and Gynecology, Keimyung University School of Medicine, Daegu, Korea\nTorsion of the fallopian tube is less frequent. Indeed, isolated bilateral fallopian tube torsion is rare and often diffi  cult to diagnose. \nThe etiology of fallopian tube torsion is still uncertain, especially when this is not associated with torsion of the ovary. We  present \na case of the torsion of isolated bilateral fallopian tube combined with tubal endometriosis. A 30-year-old woman presented \nwith chronic abdominal pain of 5-month duration and severe dysmenorrhea. Presumptive diagnosis by ultrasound and magnetic \nresonance imaging was both adnexal endometriosis. At laparoscopy, the fi  mbrial ends of both tubes were dilated, twisted and \nnecrotic changes with adhesion to omentum, which subsequently led to terminal obstruction of that tube. However, both ovaries \nand uterus were normal. Laparoscopic bilateral salpingectomy was performed. The postoperative histological report confi  rmed \nhematosalpinx with tubal endometriosis. To our knowledge, this is the fi  rst case of isolated and bilateral fallopian tubes tors ion \ncombined with tubal endometriosis.\nKeywords: Fallopian tube; Torsion; Endometriosis; Laparoscopy; Salpingectomy\nCASE REPORT\nReceived: 2011. 9.15.   Accepted: 2011.10. 5.\nCorresponding author: Jeong Ho Rhee, MD, PhD\nDepartment of Obstetrics and Gynecology, Keimyung University \nSchool of Medicine, 216 Dalseong-ro, Jung-gu, Daegu \n700-712, Korea\nTel: +82-53-250-7871  Fax: +82-53-250-7599\nE-mail: r1670416@dsmc.or.kr\nTh is is an Open Access article distributed under the terms of the Creative Commons \nAttribution Non-Commercial License (http://creativecommons.org/licenses/\nby-nc/3.0/) which permits unrestricted non-commercial use, distribution, and \nreproduction in any medium, provided the original work is properly cited.\nCopyright © 2012. Korean Society of Obstetrics and Gynecology \nKorean J Obstet Gynecol 2012;55(1):55-58\nhttp://dx.doi.org/10.5468/KJOG.2012.55.1.55\npISSN 2233-5188\n · eISSN 2233-5196\nTorsion of the fallopian tube is less frequent but signifi  cant cause \nof lower abdominal pain in reproductive age women that is dif-\nfi  cult to recognize preoperatively [1]. Although torsion of normal \novary or cystic ovary that generally involves the fallopian tube is \nrelatively common, isolated torsion of the fallopian tube is still a \npoorly recognized clinical entity that remains a rare occurrence [2]. \nAlso, there have been no specifi  c symptoms, clinical fi  ndings, im-\naging or laboratory characteristics identifi  ed for this condition [3]. \nTherefore, most of cases with isolated fallopian tubal torsion had \na delayed diagnosis and a subsequent delay of timely intervention \nthat may result in failure to save tubal function.\nWe present a case of the torsion of isolated bilateral fallopian tube \ncombined with tubal endometriosis in a 30-year-old woman that \nwas successfully treated by laparoscopic bilateral salpingectomy.\nCase Report\nA 30-year-old woman (gravid, 0; para, 0) was referred to us for \naggravation of dysmenorrhea during 5 months. Also, she present-\ned with constant dull lower abdominal pain of 5-month duration. \nShe was a virgin and had normal regular menstrual cycles. There \nwas no bowel or urinary symptom. There was no signifi  cant medi-\ncal history, excluding appendectomy 15 years ago. On physical ex-\namination, no tenderness was observed. On pelvic examination by \nrectal, palpable mass with slight tenderness in both adnexa was \nnoted. The transrectal ultrasonography demonstrated a normal \nuterus, both ovaries and evidenced the presence of round, thick-\nwalled, complex cystic structures measuring 21 × 21 mm, 53 × 34 \nmm adjacent to the right and left ovaries, respectively. Pelvic com-\nputed tomography (CT) and magnetic resonance image (MRI) (Fig. 1) \nconfi  rmed the aforementioned fi  ndings as the pelvic endometriosis.\nIn a view of the history for progressive dysmenorrhea and the psy-\n\nWWW.KJOG.ORG56\nKJOG  Vol. 55, No. 1, 2012\nchological impact on the patient, she was counseled and sched-\nuled for diagnostic laparoscopy with the possibility of surgical \nintervention as deemed necessary. On laparoscopy, the right tube \nwas observed to be twisted twice at its middle part and a thick-\nwalled cystic dilatation at its distal portion that was adherent to \nthe omentum. Symmetrically, the fi  mbrial end of the left tube was \nalso occluded and three times twisted with congestion as a result, \nbut the uterine isthmic aspect and the midsegment of the tube \nwere identifi  ed and were not ischemic (Fig. 2A–2C). The both ova-\nries with normal appearance were not involved in the torsion and \nthe uterus was normal. Endometriotic implant, such as spot, was \nonly found on the left pelvic side wall. There were no other abnor-\nmal fi  ndings on laparoscopic abdominal inspection. A laparoscopic \nbilateral salpingectomy was performed after adhesiolysis (Fig. 2D). \nThe histological examination revealed an extensive hemorrhagic \ninfarction secondary to torsion and the hematosalpinx that endo-\nmetrial gland was identifi  ed.\nFig. 1. Pelvic magnetic resonance imaging (MRI). Axial MRI view of the \npelvis.\nFig. 2. Laparoscopic views. (A) The lesion of torsion of the left fallopian tube. The fi  mbrial end of the left tube was adherent to the omentum and pelvic \nwall. (B) Adhesion of the torted right fallopian tube with the omentum. (C) Laparoscopic pelvic overview after adhesiolysis sho ws bilateral torted tubes \nand cystic dilatation at the distal portion. (D) Laparoscopic pelvic overview after bilateral salpingectomy shows normal uterus and both ovaries.\nA B\nC D\n\nWWW.KJOG.ORG 57\nSu Yeon Lim, et al. Isolated torsion of bilateral fallopian tubes\nThe postoperative course was uneventful and the patient was \ndischarged home two days later. Until now, she remains well and \nasymptomatic at follow-up.\nDiscussion\nIsolated fallopian tube torsion is a rare clinical event and the \nincidence is approximately one in 1.5 million reproductive aged \nwomen [2]. Most of the published case reports and occasional se-\nries concern unilateral torsion of the isolated fallopian tube. To the \nbest of our knowledge, our case is the fi  rst report of isolated tor-\nsion of the bilateral fallopian tubes in a reproductive age woman. \nOur patient had tubal endometriosis which may have obstructed \nthe fi  mbrial end of the tube and induced in hematosalpinx through \nretrograde menstruation [4].\nThe etiology or mechanism of isolated tubal torsion is still uncer-\ntain. However, proposed risk factors have been identifi  ed. Youssef \net al. [5] suggested that intrinsic and extrinsic factors could pos-\nsibly infl  uence the occurrence of the torsion of isolated fallopian \ntube. The predisposing intrinsic factors include an excessive length \nand tortuosity of the tube, hydrosalpinx, hematosalpinx and \npyosalpinx, previous sterilization, abnormal peristalsis or endo-\nmetriosis, while extrinsic factors include paratubal mass, peritubal \nadhesion, or uterine enlargement compressing the fallopian tubes. \nPresumably, these factors create a pivot point around which the \ntube may twist one or several times [6].\nThe diagnosis of isolated fallopian tube torsion is easily missed \npreoperatively because of a lack of pathognomonic symptoms, \nspecifi  c fi  ndings on physical examination and adequate diagnostic \ntools. When torsion occurs, the patient usually experiences acute \nsevere lower abdominal or pelvic pain. Pain may be constant or \nintermittent. Other sings of isolated tubal torsion are inconsistent \nand comprise anorexia, nausea, vomiting, or vaginal bleeding [7]. \nPyrexia, tachycardia, or leukocytosis may be present. Indeed, the \nclinical presentation often resembles other causes of abdominal \npain, for example ectopic pregnancy, pelvic infl  ammatory disease, \nruptured ovarian cyst, hemorrhagic follicle, and acute appendicitis \nwhich are far more common. Although transvaginal ultrasound \ncan easily identify enlarged adnexa and Color Doppler can also be \nused to demonstrate arterial and venous flow to adnexal struc-\nture, it must be emphasized that the presence or absence of fl  ow \ncannot rule out fallopian torsion. CT and MRI are also useful in \ndetecting twisted a vascular pedicle, thickened fallopian tubes, \nand hemorrhagic infarction. However, the sensitivity of these \nmodalities of the isolated fallopian tube torsion has not yet to be \ndetermined [8]. Therefore, most of cases with isolated fallopian \ntubal torsion had a delayed diagnosis or the diagnosis was not \nmade before surgical intervention because the clinical features \nare unspecifi  c and objective fi  ndings are uncommon. Lo et al. [8] \nnoted that in a total of 17 women with surgically proven isolated \nfallopian tube torsion, only three women had surgery within 12 \nhours, but 12 received surgery within seven days; the mean dura-\ntion of lower abdominal pain until operation was 26.7±58.2 days \n(range, 0.4 to 180 days). In our case, the time interval between \nthe clinical presentation and postoperative diagnosis of isolated \nfallopian tube torsion was 5 months.\nIn the clinical setting of suspected adnexal torsion, emergent lapa-\nroscopy is critical to both diagnosis and fertility preservation. Sev-\neral studies of adnexal torsion have demonstrated that the color, \nsize, and degree of edema do not correlate with necrosis and \nsubsequent return to normal tubal or ovarian function. Immediate \ndetorsion is always recommended, because it is unclear how long \na patient has until irreversible damage occurs [6]. However, our \npatient had bilateral salpingectomy due to obstruction of the both \ntubal terminal ends and necrosis.\n In conclusion, we suggest that in the differential diagnosis of \nlower abdominal pain in a reproductive age woman, isolated tor-\nsion of the fallopian tube should be considered, although it is the \nlow incidence. To the best of our knowledge, our case is the fi  rst \nreport of isolated torsion of the bilateral fallopian tubes combined \nwith tubal endometriosis in a reproductive age woman.\nReferences\n  1. Rizk DE, Lakshminarasimha B, Joshi S. Torsion of the fallopian \ntube in an adolescent female: a case report. J Pediatr Adolesc \nGynecol 2002;15:159-61.\n  2. Comerci G, Colombo FM, Stefanetti M, Grazia G. Isolated fal-\nlopian tube torsion: a rare but important event for women of \nreproductive age. Fertil Steril 2008;90:1198. e23-5.\n  3. Wong SW, Suen SH, Lao T, Chung KH. Isolated fallopian tube \ntorsion: a series of six cases. Acta Obstet Gynecol Scand \n2010;89:1354-6.\n  4. Ohara N, Narita F , Murao S. Isolated torsion of haematosal-\npinx associated with tubal endometriosis. J Obstet Gynaecol \n2003;23:453-4.\n  5. Youssef AF , Fayad MM, Shafeek MA. Torsion of the fallopian \ntube. A clinico-pathological study. Acta Obstet Gynecol Scand \n\nWWW.KJOG.ORG58\nKJOG  Vol. 55, No. 1, 2012\n1962;41:292-309.\n  6. Phillips K, Fino ME, Kump L, Berkeley A. Chronic isolated fal-\nlopian tube torsion. Fertil Steril 2009;92:394.e1-3.\n  7. van der Zanden M, Nap A, van Kints M. Isolated torsion of the \nfallopian tube: a case report and review of the literature. Eur J \nPediatr 2011;170:1329-32.\n  8. Lo LM, Chang SD, Lee CL, Liang CC. Clinical manifestations in \nwomen with isolated fallopian tubal torsion; a rare but impor-\ntant entity. Aust N Z J Obstet Gynaecol 2011;51:244-7.\n자궁내막증을 동반한 단독 양측성 난관 염전\n계명대학교 의과대학 산부인과학교실\n임수연, 박준철, 배진곤, 김종인, 이정호\n  난관 염전은 흔하지 않은 질환이다. 게다가 단독 양측성 난관 염전은 매우 드물고 진단하기도 어렵다. 난관 염전에 대한 정확한 원인에 \n대해서는 아직까지 알려져 있지 않고 특히 난소과 관련이 없는 단독 난관 염전인 경우에 더욱 그러하다. 우리는 난관의 자궁내막증이 동\n반된 단독 양측성 난관 염전 1예를 경험하였기에 이를 보고하는 바이다. 30세 여자 환자는 5개월간의 만성 하복부 통증과 심한 생리통을 \n주소로 내원하였다. 초음파 및 골반 자기공명영상상 양측 자궁부속기의 자궁내막증이 의심되었다. 복강경 수술 결과 양측 난관의 울혈 및 \n염전 소견을 보였고 장간막과의 유착과 난관 폐쇄를 동반하고 있었다. 양측 난소 및 자궁은 정상이었다. 복강경하 양측 난관 절제술을 시\n행하였고 조직검사상 양측 난관의 자궁내막증을 동반한 출혈성 괴사 소견이 관찰되었다. 본 증례와 같이 난관 자궁내막증을 동반한 단독 \n양측성 난관 염전은 드물어 저자들의 문헌고찰에 의하면 국내에 보고된 경우는 본 증례가 최초이다.\n중심단어: 난관, 염전, 자궁내막증, 복강경수술, 난관절제술","source_license":"CC0","license_restricted":false}