History
A 14-year-old girl presents with lower abdominal pain which developed suddenly a day ago. The pain is over the whole lower abdomen but worse on the right. It was intermittent at first but is now constant and very severe. She feels unwell in herself with no appetite and vomiting. She now feels sweaty as well. She says her bowels opened normally the day before and they are normally regular. She has never had any previous episode of pain like this. Her last menstrual period started 2 weeks ago and she has a slightly irregular cycle. She has never had any gynaecological or other medical problems in the past.
Examination
On examination she looks in pain and seems to find it difficult to get comfortable. Her tem- perature is 37.9°C, pulse 112/min and blood pressure 116/74 mmHg. She feels warm and well perfused. The abdomen is distended symmetrically with generalized tenderness, max-imal in the right iliac fossa region. There is rebound and guarding in the right iliac fossa.
Questions
• What is the differential diagnosis?
• How would you investigate and manage this girl?
Medicine
The differential diagnosis of right iliac fossa pain in this case is:
• gynaecological:
• adnexal/ovarian cyst torsion
• ovarian cyst rupture
• ovarian cyst haemorrhage
• ectopic pregnancy
• surgical:
• appendicitis
• urinary:
• urinary tract infection
• renal colic
The girl is acutely systemically unwell with an acute abdomen which would favour the diagnosis of torsion or possibly ruptured appendix. Cyst rupture and haemorrhage are not commonly associated with such systemic disturbance, though this is an important differ- ential diagnosis.
Further investigation would include a pregnancy test to exclude pregnancy, and urinaly-sis to exclude urinary tract infection or renal colic. An ultrasound should be arranged (transabdominal) to assess for an ovarian cyst or for an inflamed appendix. If an adnexal mass is confirmed, laparoscopy or laparotomy should be performed as soon as possible since adnexal torsion is associated with loss of the ovarian function if ischaemia is pro-longed and necrosis occurs. Ovarian torsion can often be managed by detorsion, though oophorectomy sometimes may be necessary.
If the diagnosis is not clear between appendicitis and ovarian torsion then joint lapar-otomy or laparoscopy with the surgical team is an appropriate approach.
KEY POINTS
• Suspected ovarian torsion is a gynaecological emergency.
• Torsion is relatively common in young girls and teenagers.
• Ultrasound is useful in detection of an adnexal mass but torsion is a clinically suspected diagnosis and necessitates urgent laparoscopy or laparotomy.
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