The findings of unilateral enlarged ovary without (or little) arterial and venous flow are said to be diagnostic of torsion. The finding of little or no venous flow is more common than no arterial flow, so persistent flow does not exclude the diagnosis. Ancillary findings include free pelvic fluid, unusual midline location of the ovary or a twisted vascular pedicle (giving the whirlpool sign). Most cases of ovarian torsion are caused by an adnexal mass (including dermoid or other cysts), with some occurring due to ovarian hypermobility. Treatment is based on early recognition and surgery, which aims to prevent necrosis and infection. Its findings should be reported urgently to the surgeons for further care, and the radiologist has an important role in this scenario.
* Presents with acute abdominal pain, enlarged abdomen and no defaecation since a few days.
What do you see?
Abdominal CT scan shows dilated colon loops with a calibre change in the sigmoid. Whirl of mesenterial vessels.
Differential diagnosis is Sigmoid volvulus. This was confirmed on OR.
Sigmoid volvulus is differentiated from a cecal volvulus by its ahaustral wall and the lower end pointing to the pelvis.
Abdominal radiographs will show a large, dilated loop of the colon, often with a few gas-fluid levels. Specific signs include coffee bean sign and absent rectal gas.
CT scan will show large gas-filled loop lacking haustra, forming a closed-loop obstruction. Specific signs include:
– whirl sign: twisting of the mesentery and mesenteric vessels
– bird’s beak sign: if rectal contrast has been administered
– X-marks-the-spot sign: crossing loops of bowel at the site of the transition
– split wall sign: mesenteric fat seen indenting or invaginating the wall of the bowel
Rectal tube insertion for treatment is successful in treating 90% of cases. Occasionally patients suffer from recurrent sigmoid volvulus, for which a surgeon may consider sigmoid colopexy (surgical fixation of the sigmoid colon), or in the surgically unfit, a percutaneous endoscopic colostomy (PEC) might be performed. The mortality rate of sigmoid volvulus is 20-25%. The most serious complication is bowel ischemia, not blow-out perforation as you might expect.
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Skull eosinophilic granuloma
Well defined lytic lesion with scalloped edges. It involves both the inner and outer table. Narrow zone of transition, no cortical breakthrough and no soft tissue component.