RADY 401: Case Presentation Pediatric Female with RLQ Pain HPI PE - - PowerPoint PPT Presentation

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Jan 17, 2023 357 likes •537 views

RADY 401: Case Presentation Pediatric Female with RLQ Pain HPI PE & WORKUP 11 year old Hispanic female presents to PE was unremarkable PED with RLQ pain A&Ox3 no acute distress Intermittent squeezing pain which

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RADY 401: Case Presentation

Pediatric Female with RLQ Pain

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HPI

 11 year old Hispanic female presents to

PED with RLQ pain

 Intermittent “squeezing” pain which

began one day prior – made worse with movement

 Non-bloody, non-bilious emesis began

day of presentation

 No fever, hematuria, or dysuria – BM

every 3-4 days

 MHx unremarkable

PE & WORKUP

 PE was unremarkable

▪ A&Ox3 – no acute distress ▪ Abdomen: nontender, non-distended,

BSx4, no rebound tenderness, no guarding

▪ Obturator and Psoas sign – negative

 ß-HCG (-)  UA –WNL  OBGYN consult

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 What studies are appropriate?

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 Initial Study –Transabdominal Pelvic US  Subsequent Study – Abdominal/Pelvic CT with IV and oral contrast

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 Right ovary (pictured) -

enlarged: measuring 5.0 x 2.6 x 5.2 cm (volume = 35mL)

 Left ovary (measurement not

pictured)– normal: measuring 3.1 x 1.8 x 3 cm (volume = 9mL)

 Cystic masses evident bilaterally

– consistent with follicles

 No abnormal pelvic fluid or focal

masses evident

Normal ovarian volume: 5 -15 mL. Right

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Diminished arterial and venous flow demonstrated within the inferior right ovary, as demonstrated above.

Power Doppler Conventional Color Doppler

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 Enlarged right ovary (see blue

arrow)- measuring 5.9 x 2.2 cm – consistent with US.

 Distended bladder, but

therwise unremarkable (see

red arrow).

 Remainder of CT was

unremarkable. Appendix,

kidneys, bowel – all WNL.

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 Yellow arrow is indicative of left

vary for comparison.

 Left ovary is measured at 2 x 1.2

cm, consistent with US.

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 Diagnostic laparoscopy with ovarian de-torsion performed

▪ Enlarged and engorged upon visual inspection ▪ Right ovary found to be torsed upon itself twice

 Follow-up appointment in 2 weeks  Repeat US in 6-8 weeks  GOOD PROGNOSIS

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 YES!  Ultrasound is the initial imaging modality of choice – especially in

pediatric patients.

 CT is good at ruling in or out ovarian torsion if the US is borderline or

inconclusive.

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US – SHOWING SIZE DISCREPANCY DOPPLER US – SHOWING DECREASED BLOOD FLOW

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CT –TRANSVERSE VIEW CT – CORONAL VIEW

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 Doppler Ultrasound

▪ 93% sensitive ▪ 98% specific

 According to recent study published in European Journal of Radiology,

the diagnostic performance of CT is not shown to be significantly different from that of US in identifying ovarian torsion in this study. The results suggest that when US demonstrates findings of ovarian torsion, the performance of another imaging exam (i.e. CT) that delays therapy is unlikely to improve preoperative diagnostic yield (Swenson, 2014).

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 US

▪ Fair Price: $225 (according to the Healthcare Bluebook for this area) ▪ Radiation dosage: none

 Abdominal/Pelvic CT with IV and Oral Contrast

▪ Fair Price: $1,515 (according to the Healthcare Bluebook for this

area)

▪ Radiation Dosage: approx. 10 mSv = comparable to natural

background radiation for 3 years!

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 Good workup is crucial for diagnosis of ovarian torsion.

▪ DDx:

▪ Appendicitis: psoas sign, obturator sign, rovsing’s sign ▪ UTI: UA ▪ Kidney Stones: Lloyd’s test + UA ▪ Ectopic Pregnancy: ß-HCG

 If all signs point to ovarian torsion – order pelvic US first, then CT if

needed.

 Act fast, this is a gynecologic emergency!

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 Albayram, F., & Hamper, U. M. (2001, October). Ovarian and adnexal torsion: Spectrum of

sonographic findings with pathologic correlation. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11587015

 Dixon, A. (n.d.). Ovarian torsion | Radiology Reference Article. Retrieved from

https://radiopaedia.org/articles/ovarian-torsion

 Goel, A. (n.d.). Normal radiological reference values | Radiology Reference Article. Retrieved

from https://radiopaedia.org/articles/normal-radiological-reference-values

 Healthcare Bluebook, your free health care guide to fair ... (n.d.). Retrieved from

http://www.bing.com/cr?IG=E7D564FAAF634746AD7938E8843462A8&CID=275518CDD4E86B 872D8514F8D5156AAE&rd=1&h=R8x_uAbr0_geI-HCkf1uJ93CJ7xPuFPEL- a4OXgbAHE&v=1&r=http://www.healthcarebluebook.com/&p=DevEx.LB.1,5516.1

 Ovarian torsion: Case–control study comparing the sensitivity and specificity of

ultrasonography and computed tomography for diagnosis in the emergency department. (2014, January 08). Retrieved from https://www.sciencedirect.com/science/article/pii/S0720048X14000023

 Patel, M. S. (n.d.). Ovarian torsion | Image. Retrieved from