L.B. was a 45-year-old mother of two boys who was brought to the emergency department by her husband. She was having severe lower pelvic pain, and I was just starting my 24-hour shift.
In fact, when I start at 7 a.m., we normally do a 15-minute “handoff” of who is in the hospital and needs to be seen, as well as any other problems that may arise. The call from the ER came two minutes after 7. It was the start of a busy day.
L.B.’s pain had started suddenly 14 hours before, a sharp on-and-off pulsating on her lower right side. She was an obviously intelligent woman who never complains (according to her husband).
To figure out the cause of these symptoms, the work up in such a case includes testing for ectopic pregnancy, appendicitis, ruptured ovarian cyst, an abscess, and, what I already suspected, a torsed ovary (twisted ovary). Her white blood count hemoglobin were all normal. She'd had a normal appetite until the pain started. Appendicitis usually presents with no or markedly reduced appetite for a day or so. Ovarian cyst pain is usually constant.
Ovarian torsion, which often causes a pulsating, severe pain, is either partial or complete twisting of the ovary on its pedicle or stalk. This reduces or cuts off the blood supply to the ovary, and it starts to die. This is similar pain as in a heart attack, when the blood supply to that portion of the heart is cut off. Muscle cells are dying, and it hurts terribly. The primary source for such an event can be complicated by a large ovarian cyst or mass.
L.B.’s pelvic ultrasound showed a very large, 12-centimeter ovarian mass. We look for blood flow to the ovary when diagnosing a torsion, but that’s not always helpful. The mass didn’t look pretty on ultrasound, and I was now worried about ovarian cancer, which can also “twist.”
I was looking at the double whammy. Normally if we suspect ovarian cancer, we like to be prepared for what we may find. This was a Sunday morning, and there was no surgical oncologist available. The morphine we were giving this poor woman wasn’t holding the pain back. She needed to be operated on, and sooner rather than later. We were able to get a quick CAT scan to make sure there were no other hidden problems, such as those that may be found with any potential cancer.
The good thing about this case was that L.B. was 45 and had had all her children. She was not a 15-year-old girl. I have seen those cases as well.
When an adnexal torsion is suspected, the surgery of choice is laparoscopy, which is placing a few tubes directly into the belly instead of opening the patient up like in a cesarean section. This would make for a less invasive procedure and quicker recovery. I was doubtful I would succeed in this case, but I had to try.
When we have a surgical emergency, the hospital works very quickly. The operating personnel were getting the room ready, and the anesthesiologist was preparing what he needed. Luckily, the patient hadn’t had food or water in more than 10 hours, which made it safer to administer anesthesia.
I explained the concerns we had to the patient (who was in severe pain but very alert) and her husband. At 45, she didn’t care if I could save the ovary. I told them the ovary must go, since it was 12 centimeters and we were concerned about cancer. I was hopeful that if it was cancer, I wouldn’t find any spread. I also told them I would examine her in the operating room and decide if I could even try a laparoscopy, but that I would probably need to perform a C-section type surgery, called a pfannenstiel.
It was now 9 a.m. Things were moving fast.
With the patient under anesthesia, I could easily feel this huge mass. L.B. was thin. In the ER, she was in too much pain for it to be physically examined by touch through her tender abdomen. The mass went all the way up to her belly button. This was not going to be a laparoscopy procedure.
I entered her belly very carefully, so as not to accidentally rupture this mass. I did what is called pelvic washings and saw this black and blue twisted adnexal (ovary and fallopian tube) mass. I was able to easily and carefully raise it out of the pelvis. It was twisted twice on its own pedicle. There would be no way to know the true pathology for several days. The mass was excised and sent off. The rest of the pelvis was completely clean, with no other disease process seen.
It was a good result for this lovely couple. I was able to close the abdomen easily, and she went to her room a few hours later. She did so well that she went home the next day, only being sore from the surgery.
The pathology came back later that week: no cancer, but a dead ovary. I’ll take that report.
