Twist and Shout! Pediatric Ovarian Torsion Clinical Update and Case Discussion Eric R. Schmitt, MD, MPH,*Þþ Steven S. Ngai, MD,þ§|| Marianne Gausche-Hill, MD,*Þþ and Richard Renslo, MDþ§|| Abstract: Ovarian torsion (OT) in the pediatric patient is an uncom- mon event and a challenging diagnosis. Clinicians caring for children in the acute setting should be aware of the symptoms and the diagnostic findings of OT. All patients suspected to have OT require consultation with gynecology; however, there is some controversy regarding the best operative intervention. In this article, case discussions will serve as a platform for discussing the epidemiology and clinical manifestations of pediatric OT, as well as reviewing the latest evidence related to the diagnosis and treatment. Key Words: ovarian torsion, ultrasound, oophorectomy, laparoscopy (Pediatr Emer Care 2013;29: 518Y526) TARGET AUDIENCE This CME activity is intended for physicians who care for children. Pediatricians, emergency physicians, pediatric emer- gency physicians, surgeons, and gynecologists will find this in- formation especially useful. LEARNING OBJECTIVES After completion of this article, the reader should be able to: 1. Identify the epidemiology and pathophysiology of ovarian torsion (OT) in the pediatric patient. 2. Use clinical presentation and diagnostic imaging to diag- nose OT in the pediatric patient. 3. Manage OT in the pediatric patient presenting in the emer- gency department. CASE 1: A 13-YEAR-OLD WITH RIGHT LOWER QUADRANT PAIN History of Present Illness A 13-year-old Hispanic girl presents to the emergency department (ED) after 3 hours of constant ‘‘cramping’’ right lower quadrant pain that awoke her from sleep. Since the onset of pain, she has had 10 episodes of emesis. There are no other associated symptoms, and result for review of systems is negative except for 1 day of mild cough. She reports no previ- ous episodes of similar pain. She denies any sexual activity, and her last menstrual period was approximately 3 weeks previously. She has no significant medical history and no previous surgeries. Vital Signs Temperature is 36.5-C; blood pressure is 134/80 mm Hg; heart rate is 66 beats per minute; respiratory rate is 20 breaths per minute; and pulse oximetry reads 98% on room air. Physical Examination The patient is in moderate distress secondary to pain but has a normal mental status. Her head and neck examination demonstrates neither icterus nor meningismus. Her lungs are clear to auscultation, and her cardiac examination result is normal. Her abdomen is tender to palpation in the right lower quadrant and suprapubic area, but there is no rebound or guard- ing. Extremity and neurological examinations are unremarkable. Laboratory Values White blood cell count is elevated at 12,300/HL with 86% polymorphonucleocytes. Hemoglobin and platelets are normal. Urinalysis is unremarkable, and point-of-care urine pregnancy test result is negative. Questions: 1. How common is OT in children? 2. What factors predispose children to OT? 3. How does OT present clinically? 4. What other entities can present similarly and complicate the diagnosis of OT? 5. How will you proceed in the diagnostic workup of this patient? How Common Is OT in Children? Ovarian torsion is an infrequent cause of acute abdominal pain, in one estimate accounting for only 2.7% of cases in adult women. 1 Pediatric patients, on the other hand, account only for approximately 15% of all cases of OT, 1 with major centers reporting 0.3 to 3.5 cases of pediatric OT per year. 2 Ovarian torsion is described in all ages and is overall more common after menarche, although among pediatric patients the average age is 10 years and many patients are premenarchal. In one series, the age range was 3 to 15 years (mean, 10.2), and 15 of 22 patients were premenarchal. 3 Guthrie et al 4 identified 1232 pediatric cases (ie, e20 years) of OT from the Kids’ Inpatient Database in 2006. This database included data from 3739 hospitals in 38 states, allowing Guthrie et al to calculate a na- tional estimate of 1965 total cases or an annual incidence of 4.9 per 100,000 female patients aged 1 to 20 years. 4 This number is comparable with the rate of testicular torsion in a similar age group (4.5 per 100,000 male patients aged 1Y25 years). 4 What Factors Predispose Children to OT? Ovarian torsion begins when an ovary twists on its pedi- cle. As the lymphatic drainage and venous outflow become CME REVIEW ARTICLE 518 www.pec-online.com Pediatric Emergency Care & Volume 29, Number 4, April 2013 Pediatric Emergency Fellow and Clinical Instructor (Schmitt); Resident Physician (Ngai); Professor, Vice Chair, Director (Gausche-Hill); Chief, Associate Program Director for the Diagnostic Radiology Residency Train- ing Program, Professor (Renslo); *Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance; †Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles; ‡Los Angeles Bio- medical Research Institute, Harbor-UCLA; and §Department of Radiology, Harbor-UCLA Medical Center, Torrance; and ||Department of Radiologic Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA. The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial or- ganizations pertaining to this educational activity. Reprints: Eric R. Schmitt, MD, MPH, Department of Emergency Medicine, Harbor-UCLA Medical Center, 1000 W. Carson St, Box 21, Torrance, CA 90509 (e-mail: ericrschmitt@yahoo.com). Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0749-5161 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.