Emerg Radiol (2010) 17:335–338
DOI 10.1007/s10140-009-0851-5
CASE REPORT
Acute ovarian torsion in an infant: diagnostic clues on supine
and decubitus abdominal radiographs confirmed
by ultrasound
Lucas Marino DeJohn & Arabinda K. Choudhary &
Danielle K. Boal
Received: 26 October 2009 / Accepted: 9 November 2009 / Published online: 9 December 2009
# Am Soc Emergency Radiol 2009
Abstract Acute ovarian torsion is an uncommon yet
important diagnostic consideration in any female pediatric
patient presenting with acute abdominal pain. A 2-month-
old infant presented to the emergency department with a
several-day history of constipation. Evaluation with plain
radiographs demonstrated a subtle yet persistent soft tissue
mass in the right pelvis. Follow-up ultrasound revealed
characteristic findings for ovarian torsion and subsequent
salpingo-oophorectomy was performed confirming the
diagnosis. Acute ovarian torsion is an uncommon and
frequently overlooked diagnosis in female infants presenting
with gastrointestinal or urinary tract symptoms. Careful
assessment of plain radiographic findings may aid in the
further management of this difficult diagnosis in female
infants. Ultrasound is recommended to confirm the diagnosis.
Keywords Acute ovarian torsion . Infant . Plain radiograph .
Ultrasound
Introduction
Acute ovarian torsion is an uncommon etiology for acute
abdominal pain particularly in young infants and is thus
many times overlooked in the differential diagnosis.
L. M. DeJohn (*) : A. K. Choudhary : D. K. Boal
Department of Radiology,
Penn State Milton S Hershey Medical Center,
500 University Drive,
Hershey, PA 17033, USA
e-mail: ldejohn@hmc.psu.edu
A. K. Choudhary
e-mail: achoudhary@hmc.psu.edu
D. K. Boal
e-mail: dboal@hmc.psu.edu
Nevertheless, because of the significant morbidity and
mortality associated with delayed diagnosis, ovarian torsion
remains an important diagnostic consideration in a female
patient of any age presenting with acute abdominal pain.
Our aim is two-fold: (1) Illustrate the utility of close
attention to detail when evaluating the abdominal radio-
graph which is still likely the first investigative evaluation
of any child presenting to the emergency department with
gastrointestinal signs and symptoms. Careful assessment of
plain films can provide useful information that may lead to
further confirmatory diagnostic imaging, especially when
history and physical examination are limited in infants. (2)
Emphasize the fact that acute ovarian torsion in infants
usually presents with vague gastrointestinal or urinary tract
symptoms rather than pain. We would also like to reiterate
the classic findings of ovarian torsion on ultrasound.
Case
A 2-month-old female patient presented to the emergency
department with 4 days of constipation, being somewhat
inconsolable and vomiting. The patient was evaluated by
her primary care physician two days prior and was
diagnosed and treated for constipation. The past medical
and birth history were otherwise unremarkable. Physical
examination in the emergency department demonstrated a
soft and nondistended abdomen with positive bowel
sounds. Supine and decubitus abdominal radiographs
demonstrated a rounded soft tissue density in the right
lower quadrant (Fig. 1a, b) that persistently displaced air-
filled bowel on both the supine and decubitus radiograph.
This soft tissue density was separate from the bladder and
located in the right lower quadrant. In addition, air could be
seen within loops of bowel around yet distinctly separate
336
Fig. 1 a Supine radiograph
demonstrating mass effect in
the right lower quadrant with
displaced loops of bowel medi-
ally and superiorly (arrows). b
A left lateral decubitus radio-
graph shows persistent mass
effect with displaced bowel
loops in the right lower quadrant
(arrows)
from the soft tissue density. These findings were concerning
for a pelvic mass, and thus, an ultrasound was recom-
mended. A transabdominal ultrasound was obtained which
demonstrated a heterogeneous mass in the right lower
quadrant measuring 2.9×3.0×2.9 cm with several internal
cysts. Doppler flow was absent internally within this mass
(Fig. 2). A separate right ovary was not identified. The left
ovary showed few small cysts but otherwise appeared
normal with good blood flow. The diagnosis of acute
ovarian torsion was made.
The patient was taken to surgery where the right tubo-
ovarian torsion was found and salpingo-oophorectomy was
performed. In addition, three separate cysts were identified
on the left ovary, which was fairly loose on its pedicle. The
three cysts were subsequently aspirated and the largest cyst
(2 cm) underwent partial cystectomy. Afterwards, a left
Fig. 2 Ultrasound shows a large heterogeneous ovarian mass with
discrete cysts (arrows). The uterus is partially visualized (arrowhead)
Emerg Radiol (2010) 17:335–338
oophoropexy was performed securing the left ovary to the
peritoneum. Pathology demonstrated a necrotic right ovary
and fallopian tube with no viable tissue.
Discussion
Ovarian torsion is a rare condition in young female patients,
however, it can occur in any age group. Because of the risk
of significant morbidity and even mortality, ovarian torsion
should remain an important diagnostic consideration in any
female pediatric patient presenting with acute abdominal
pain. Ovarian torsion has been documented in all female
pediatric populations including fetus, neonate, infants, and
older children/adolescents.
Although believed to be uncommon in infants, ovarian
torsion is probably often overlooked since its presentation
mimics acute gastrointestinal and urinary tract problems
[1]. In a recent retrospective study of 97 pediatric patients
diagnosed with ovarian torsion in a children's hospital over
15 years, the age distribution was bimodal with the largest
number of cases (16%, 16/97) in the less than 1 year age
group, and the other peak at 12 years with 12 cases [2]. The
symptoms in the infant group included prenatal imaging
(50%), presence of a mass (38%), and feeding intolerance
(6%) in contrast to those over 1 year where pain was the
predominant chief complaint (97%). No further analyses
were provided in this report on the infant subset of patients.
But, if we exclude non-acute cases of ovarian torsion such
as prenatal mass, there were less than eight cases of acute
ovarian torsion in this study in those less than 1 year of age.
This reflects the limitations in assessing for pain in an
infant and the difficulty in diagnosing an uncommon
condition.
Emerg Radiol (2010) 17:335–338
Hamrick described a case report of a 6-week-old female
patient that presented with nonspecific symptoms including
fussiness, low grade fever, one episode of vomiting, and
poor feeding. The patient was subsequently diagnosed with
ovarian torsion [3].
Swischuck recently described ovarian torsion in a 6-
month-old patient with nausea, vomiting, decreased oral
intake, irritability, lethargy, and colicky abdominal pain
suggestive of intussusception with mild tenderness on
physical examination. In this article, he suggested
ovarian torsion should be considered in the differential
of any young female infant who presents with acute
gastrointestinal or urinary tract problems when no other
etiology for the symptoms is discovered [1].
The clinical presentation of pediatric ovarian torsion is
classically nonspecific and dependent on the age of the
patient. Physical examination in neonates and infants, in
particular, is challenging thus making the diagnosis more
difficult. These younger patients may present with inter-
mittent colicky lower abdominal pain with or without an
associated mass. In addition, it is not uncommon for
neonates and infants to present with gastrointestinal
symptoms such as vomiting or constipation. Older children
and adolescents tend to present with more focal symptoms
including pain, nausea, and fever with or without a palpable
mass.
Typically, the first diagnostic imaging study ordered
on patients presenting to the emergency department with
acute abdominal symptoms is an abdominal radiograph.
One must carefully scrutinize the plain radiograph to
look for any signs suggesting the diagnosis thus leading
to further confirmatory diagnostic imaging. Such subtle
signs include a soft tissue mass in the pelvis with
associated mass effect on adjacent loops of air-filled
bowel which persists on supine and decubitus positioning
as in our case. A distended bladder could be mistaken
for a pelvic soft tissue mass, however, this can easily be
differentiated from ovarian torsion either clinically and/or
at the time of ultrasound imaging. Because of the
subtlety of the findings, these signs can prove to be a
diagnostic challenge for the radiologist-in-training and
for emergency room physicians. Therefore, any finding
suspicious for a soft tissue mass in the pelvis in a female
patient with acute abdominal pain on plain radiograph
should be further evaluated with ultrasound.
The sonographic findings of ovarian torsion have been
well documented within the literature. In a recent study by
Servaes et al., the most common sonographic finding in
children with ovarian torsion was a heterogeneously
enlarged ovary with a volume 12 times greater than the
contralateral side. The majority of cases occurred on the
right side. In this study, Doppler and color flow were
unreliable predictors in patients with ovarian torsion, as
337
greater than 60% of patients had either documented arterial
or venous flow [4].
In our case, the patient presented with acute gastro-
intestinal symptoms and a nonspecific physical examina-
tion. The plain radiograph demonstrated subtle mass
effect in the right pelvis which persisted on supine and
decubitus positioning. A follow-up ultrasound showed
classic findings of acute ovarian torsion including
heterogeneous enlargement of the right ovary with
absence of Doppler flow. We do not recommend
abdominal radiographs as the primary method to assess
for ovarian torsion in patients with strong clinical
suspicion, however, subtle signs can be found that may
help direct the clinical team to the correct diagnosis and
appropriate additional diagnostic imaging when the
presentation is nonspecific.
Timely diagnosis and early management are imperative
to minimize the morbidity and mortality associated with
acute ovarian torsion in the pediatric patient. It is not an
uncommon cause of death [5, 6]. In a recent study by
Anders et al., they found that ovarian torsion is a more
salvageable condition than what was previously thought
[7]. They reported a salvage rate of 27% in 22 pediatric
patients surgically diagnosed with ovarian torsion at a
single children's hospital over a period of 15 years even
after prolonged duration of symptoms (7–159 h). They
concluded that urgent imaging and aggressive surgical
approach will improve outcome even if the presentation is
delayed.
Conclusion
The learning points from this case include:
1. Acute ovarian torsion is often an overlooked diag-
nosis and may mimic acute gastrointestinal or urinary
tract problem. It is therefore important to consider
acute ovarian torsion in any female patient presenting
with gastrointestinal or urinary tract symptoms when
an etiology for symptoms is not elucidated. In these
cases, ultrasound will be the diagnostic modality of
choice.
2. Careful assessment of plain radiographs may demon-
strate a subtle but persistent soft tissue mass in the
pelvis that displaces loops of air-filled bowel on both
supine and decubitus positioning. Plain film interpreta-
tion is increasingly a lost skill in the age of high-tech
imaging.
3. An enlarged heterogeneous ovarian mass with
characteristic enlarged follicles is diagnostic of
ovarian torsion and urgent surgical intervention is
indicated.
338
References
1. Swischuk LE (2008) Abdominal pain in a female infant: suspected
intussusception. Pediatr Emerg Care 24(9):643–644
2. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N
(2009) Cannot exclude torsion—a 15-year review. J Pediatr Surg
44(6):1212–1216
3. Hamrick HJ, Fordham LA (1998) Ovarian cyst and torsion in a
young infant. Arch Pediatr Adolesc Med 152(12):1245–1246
Emerg Radiol (2010) 17:335–338
4. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS (2007)
Sonographic findings of ovarian torsion in children. Pediatr Radiol
37(5):446–451
5. Fitzhugh VA (2008) Adnexal torsion leading to death of an infant. J
Pediatr Adolesc Gynecol 21:295–297
6. Havlik DM (2002) Sudden death in an infant resulting from torsion
of the uterine adnexa. Am J Forensic Med Pathol 23(3):289–291
7. Anders JF, Powell EC (2005) Urgency of evaluation and outcome
of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc
Med 159(6):532–535