Sigmoid volvulus in a postmenopausal woman with ovarian cyst torsion: A rare case report with review of literature.

A 50-year-old postmenopausal woman was admitted to the hospital with complaints of colicky left-sided abdominal pain, absence of defecation and flatus, and recurrent episodes of non-bloody vomiting over the past three days. She had a body mass index of 30, no significant medical or drug history, and no family history of breast or ovarian cancer. On examination, the patient was hemodynamically stable. Abdominal examination revealed severe generalized distention without guarding or rebound tenderness, and bowel sounds were sluggish. Digital rectal examination showed an empty rectal ampulla with no evidence of rectal bleeding. A large mass was palpated on the left side of the abdomen and confirmed during vaginal examination. No signs of peritoneal irritation were observed. The patient was managed with intravenous hydration, prophylactic antibiotics, and nasogastric decompression. Initial laboratory tests revealed mild leukocytosis with a left shift and mild anemia. Electrolytes, liver and renal function tests, and serum levels of amylase, lipase, and venous blood gas (VBG) were all within normal limits. An urgent abdominal radiograph ( Fig. 1 ) and abdominopelvic computed tomography (CT) scan were performed. The CT scan ( Fig. 2 ) revealed a large multi-cystic mass measuring 195 × 187 mm originating from the left ovary, with suspicious findings of ovarian torsion. Concurrent sigmoid volvulus with vascular compromise and moderate abdominopelvic free fluid was also observed. All other abdominopelvic organs were within normal limits. Fig. 1 Abdominal X-ray Fig. 1 “Abdominal X-ray in the supine position illustrates important findings: Significant dilation of the colon, with a soft tissue density visible in the center of the abdomen, suggestive of colon obstruction, Transition point of the dilated colon identified in the left lower quadrant (marked with a red arrow). Dilation of the small bowel is also evident.” Fig. 1 Fig. 2 Contrast-enhanced CT images of the abdomen Fig. 2 “Contrast-enhanced CT images of the abdomen in the portal venous phase in axial (A), coronal (B), and sagittal (C) planes demonstrate key findings, (A) The left adnexa contain a multiloculated cystic mass with thin septations. The left ovary, marked with a red star, is displaced to the midline, and the twisted ovarian pedicle, indicated by a yellow arrow, is consistent with ovarian torsion, (B) The dilated sigmoid colon is shown with a blue star. The “X-marks-the-spot sign,“ representing crossing loops of bowel at the transition point, is highlighted with red arrows, while the twisted mesentery and mesenteric vessels, forming the “whirl sign,“ are indicated by a yellow arrow. This twisting occurs at the same location as the twisted ovarian pedicle, (C) The “X-marks-the-spot“ transition point is shown with a red arrow, and the twisted left ovarian pedicle, depicted with a yellow arrow, appears to be contributing to the sigmoid volvulus.” Fig. 2 Abdominal X-ray Fig. 1 “Abdominal X-ray in the supine position illustrates important findings: Significant dilation of the colon, with a soft tissue density visible in the center of the abdomen, suggestive of colon obstruction, Transition point of the dilated colon identified in the left lower quadrant (marked with a red arrow). Dilation of the small bowel is also evident.” Contrast-enhanced CT images of the abdomen Fig. 2 “Contrast-enhanced CT images of the abdomen in the portal venous phase in axial (A), coronal (B), and sagittal (C) planes demonstrate key findings, (A) The left adnexa contain a multiloculated cystic mass with thin septations. The left ovary, marked with a red star, is displaced to the midline, and the twisted ovarian pedicle, indicated by a yellow arrow, is consistent with ovarian torsion, (B) The dilated sigmoid colon is shown with a blue star. The “X-marks-the-spot sign,“ representing crossing loops of bowel at the transition point, is highlighted with red arrows, while the twisted mesentery and mesenteric vessels, forming the “whirl sign,“ are indicated by a yellow arrow. This twisting occurs at the same location as the twisted ovarian pedicle, (C) The “X-marks-the-spot“ transition point is shown with a red arrow, and the twisted left ovarian pedicle, depicted with a yellow arrow, appears to be contributing to the sigmoid volvulus.” The patient underwent immediate surgical intervention by laparotomy. Upon abdominal entry, a moderate amount of serous peritoneal fluid was noted and collected for cytologic assessment. The left ovary was gangrenous, containing a massive 20-cm cyst weighing 2300 g with a smooth border, which had undergone torsion with three complete turns ( Fig. 3 ). The mass was surrounded by a large, air-filled, dilated loop of sigmoid colon twisted around its mesentery and the left utero-ovarian ligament. Fig. 3 gangrenous ovary and sigmoid volvulus Fig. 3 Gangrenous left ovary with a massive 20-cm cyst with smooth border containing hemorrhagic fluid encircled by a large air-filled dilated loop of sigmoid colon twisting about its mesentery and left utero-ovarian ligament, (A) Before reduction of SV, (B) Reduced SV through counterclockwise reduction after unilateral salpingo-oophorectomy; revascularization is prominent in sigmoid colon compared with A. Fig. 3 gangrenous ovary and sigmoid volvulus Fig. 3 Gangrenous left ovary with a massive 20-cm cyst with smooth border containing hemorrhagic fluid encircled by a large air-filled dilated loop of sigmoid colon twisting about its mesentery and left utero-ovarian ligament, (A) Before reduction of SV, (B) Reduced SV through counterclockwise reduction after unilateral salpingo-oophorectomy; revascularization is prominent in sigmoid colon compared with A. The bowel appeared ischemic but not gangrenous; therefore, Hartmann's procedure (subtotal colectomy with end colostomy) was performed due to distortion of both bowel ends. Unfortunately, intraoperative frozen section analysis was not available. Gross examination of the cyst revealed no papillary projections and consisted entirely of clots and hemorrhagic material. The right ovary and uterus appeared normal, with a smooth surface appropriate for the patient's age. Accordingly, unilateral salpingo-oophorectomy was performed on the left side without further surgical staging. No palpable lymph nodes were detected in the pelvic or para-aortic regions, the omentum appeared normal, and no abnormalities were found upon exploration of the abdominopelvic cavity—supporting the likelihood of a benign lesion. The postoperative course was uneventful, and the patient was discharged on the ninth postoperative day. Histopathological analysis confirmed a hemorrhagic cyst with evidence of torsion and abscess formation. The resected sigmoid colon showed edema, ischemic changes, and extensive mucosal injury. Peritoneal cytology was negative for malignant cells. Assessing tumor markers indicated positivity for CA125 (114 U/mL) and CA 19–9 (234 U/mL) and negativity for HE4, BHCG, CEA, and ROMA value.

S.R.: writing the manuscript and one of the surgeon. H.K.: Main surgeon of the patient. S.D.: reporting and interpretation of patient's imaging. I.A.: one of the surgeon. A.T.: one of the surgeon. N.Z.: Editing the final manuscript, corresponding.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

ethics approval is not required for case reports or case series deemed not to constitute research at our institution.

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Narges Zamani.

In conclusion, the findings should be interpreted with caution due to the inherent limitations of a single case report and the uniqueness of our patient's presentation including her postmenopausal status, absence of typical risk factors for volvulus, and lack of significant comorbidities. However, this case highlights three key clinical insights: 1. Caution is required when selecting patients for primary endoscopic detorsion, due to the high failure rate in SV. 2. OCT should be considered in the differential diagnosis of intestinal volvulus in female patients of all ages, including those who are postmenopausal. 3. Despite benign histopathologic findings in our patient, comprehensive preoperative and intraoperative evaluation—using imaging, lab data, and frozen section (when available)—is essential to avoid suboptimal or unnecessarily extensive surgery. Caution is required when selecting patients for primary endoscopic detorsion, due to the high failure rate in SV. OCT should be considered in the differential diagnosis of intestinal volvulus in female patients of all ages, including those who are postmenopausal. Despite benign histopathologic findings in our patient, comprehensive preoperative and intraoperative evaluation—using imaging, lab data, and frozen section (when available)—is essential to avoid suboptimal or unnecessarily extensive surgery.

SV is more common in older men (mean age:71 years, Male/Female ratio:1.9), adults with chronic constipation (48 %), and individuals with neuropsychiatric disorders (31.3 %), but it can occur at any age [ 7 ]. Other risk factors include an enlarged colon, a long mesentery, pregnancy, and abdominal adhesions. Neuroleptic drugs can also interfere with colonic motility and may trigger volvulus. Our patient had none of the listed risk factors except for a history of chronic constipation. Despite reports of a few cases of intestinal obstruction caused by benign and malignant ovarian masses [ 8 ] encircling fallopian tubes [ 9 ] tubo-ovarian abscesses [ 10 ] and endometriosis [ 11 ] to the best of our knowledge, this is the first reported case of obstructing SV concurrent with postmenopausal OCT in the literature. Postmenopausal OCT is a rare entity, with an incidence of approximately 2.7 % [ 12 ]. Due to its rarity in this age group, the diagnosis is often missed, which can lead to more severe outcomes, as history and examination are often less reliable in these patients. A large proportion (30 %) of ovarian masses in postmenopausal women are malignant [ 13 ]. However, the reported risk of malignancy in postmenopausal patients with OCT varies between 3.8 and 22 % [ 14 , 15 ]. Large ovarian cysts (>10 cm) are generally not malignant, with histopathology often indicating serous or mucinous origin [ 16 ]. In one study, Ganer et al. found that the diameter of adnexal lesions in postmenopausal women was larger than in premenopausal women, consistent with previous findings [ 17 ]. Malignant masses tend to cause inflammation and adhere to surrounding tissues, making torsion less likely in this age group [ 13 ]. It is important to understand that the risk of malignancy in adnexal masses is higher than the likelihood of torsion [ 15 ]. Since the radiologic appearance of torsion may mimic malignancy, or vice versa, and typical symptoms may be absent in postmenopausal patients, both diagnoses should always be considered. Up to 25 % of SV patients present emergently with signs of peritonitis and shock—diaphoresis, tachypnea, tachycardia, fever, and hypotension [ 1 ]. These signs are typically associated with bowel ischemia or perforation and require emergent intervention. On physical examination, patients often demonstrate abdominal distention and tympany, and may or may not have tenderness, depending on the extent of bowel compromise [ 5 ]. A classic finding is an empty rectal vault on digital rectal examination [ 5 ], as was seen in our patient. Laboratory findings may be normal or may show leukocytosis, dehydration, electrolyte disturbances, acute kidney injury, or coagulopathy, depending on clinical status [ 1 ]. Abdominal radiography may demonstrate small bowel dilation with air-fluid levels if the patient has an incompetent ileocecal valve [ 5 ]. CT scan—with or without rectal contrast—can provide additional diagnostic clarity and confirm ischemia or perforation when suspected. Common CT findings include a mesenteric swirl, loss of bowel wall enhancement, pneumatosis intestinalis, and portal venous gas—all of which are suggestive of ischemia with necrosis. A water-soluble contrast enema may be considered when CT is inconclusive and typically shows a “bird's beak” appearance with smooth tapering at the obstruction site [ 5 ]. Key pillars of SV management include assessing colonic viability, relieving obstruction, and preventing recurrence [ 18 ]. According to the 2021 Clinical Practice Guidelines from the American Society of Colon and Rectal Surgeons (ASCRS [ 19 ]: 1. Patients without hemodynamic instability, peritonitis, or perforation should undergo lower endoscopy to assess viability, detorse the colon, and decompress the bowel. 2. Urgent sigmoid resection is indicated when endoscopic detorsion fails or when the colon is nonviable or perforated. 3. Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrence. Patients without hemodynamic instability, peritonitis, or perforation should undergo lower endoscopy to assess viability, detorse the colon, and decompress the bowel. Urgent sigmoid resection is indicated when endoscopic detorsion fails or when the colon is nonviable or perforated. Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrence. In regions with high SV prevalence—referred to as the “volvulus belt,” including Africa, South America, Russia, Eastern Europe, the Middle East, India, and Brazil—many studies have advocated for primary surgery. In a retrospective study from Tunisia, Trigui et al. [ 20 ]reported that primary surgery is a good alternative when endoscopy is unavailable and has the benefit of preventing early recurrence and the need for subsequent surgery. In our patient, the presence of a large ovarian mass with torsion rendered her unsuitable for endoscopic detorsion. Without surgery, recurrent SV rates are high—ranging from 45 to 90 %—and each recurrence increases the risk of ischemia and perforation [ 18 ].

Not commissioned, externally peer-reviewed.

Colonic volvulus occurs when a redundant segment of the colon twists around its mesentery, leading to large bowel obstruction and potential ischemia [ 1 ]. Although volvulus can occur in any redundant colonic segment, it most commonly involves the sigmoid colon and cecum [ 2 ]. Patients with sigmoid volvulus (SV) may present with nonspecific symptoms, including abdominal pain, bloating, cramping, nausea, vomiting, and obstipation. Some may also report a history of chronic constipation with acute worsening [ 3 ]. The diagnosis of SV is typically made using radiographic imaging. Abdominal radiography may reveal the classic “coffee bean” sign pointing toward the upper abdomen in 60–80 % of cases [ 4 , 5 ]. In hemodynamically stable patients with no evidence of bowel compromise, endoscopic detorsion is the preferred initial management, followed by interval colectomy. However, emergent colectomy with or without colonic diversion is necessary in more severe presentations [ 3 ]. To the best of our knowledge, this is the first documented case in the literature of concurrent SV and ovarian cyst torsion (OCT) in a postmenopausal woman, where the torsed ovarian mass may have acted as a mechanical trigger. This case provides a unique perspective on the interplay between gynecologic and gastrointestinal pathologies in an atypical demographic. The case has been presented following the SCARE criteria [ 6 ].

SV sigmoid volvulus OCT Ovarian cyst torsion CA125 cancer antigen 125 CA 19–9 Carbohydrate antigen 19–9 HE4 Human epididymis protein 4 BHCG Human chorionic gonadotropin CEA carcinoembryonic antigen ROMA value, risk of ovarian malignancy algorithm ASCRS The American Society of Colon and Rectal Surgeons sigmoid volvulus Ovarian cyst torsion cancer antigen 125 Carbohydrate antigen 19–9 Human epididymis protein 4 Human chorionic gonadotropin carcinoembryonic antigen value, risk of ovarian malignancy algorithm The American Society of Colon and Rectal Surgeons

nothing to declare.