Torsion in an Otherwise-Normal Ovary with a Giant Hematosalp
A 23-year-old woman (gravida 0, para 0) presented to our emergency department with complaints of acute lower abdominal pain after sexual intercourse followed by nausea. She did not use any medication for contraception. Physical examination revealed a soft and flat abdomen with no tenderness in the pouch of Douglas. Blood examination showed a slightly elevated white blood cell (WBC) count of 9550/?l, C-reactive protein (CRP) 2.3?mg/dl, and a negative human chorionic gonadotropin. On ultrasound, the left adnexa was not enlarged, and a corpus luteum-like cyst, 3?cm in size, was detected inside the ovary. A small number of ascites was also observed.

Based on the above findings, provisional diagnosis of ovarian hemorrhage was made, and conservative treatment with oral painkillers was administered. Three days later, the patient returned to the emergency department with increased intensity of lower abdominal pain along with strong nausea and diarrhea. Her vitals showed an increased pulse rate of 103?bpm and body temperature of 37.7°C. Her abdomen was generally soft, but there was moderate tenderness in the pouch of Douglas. Blood examination showed elevated inflammation-related factors. Her platelet counts were kept in a normal range. Ultrasonography revealed a markedly enlarged adnexal mass in the left lower abdomen. The mass had a complex solid cystic structure with a unilocular cyst much larger than a solid component. Contrast-enhanced computed tomography (CT) was then performed. The mass, located on the ventral side of the uterus, showed a weak contrast effect and a separate cystic compartment connected to the solid area with a band-like structure. Based on the above findings, adnexal torsion was suspected; however, the composition of enlarging cystic mass and the reason for rapid enlargement over a few days were unclear although we discussed it fully with radiologists. Nonetheless, to rule out ovarian torsion, laparoscopic surgery was performed immediately.

On laparoscopic surgery, the whole left adnexa was found to be markedly swollen and twisted to at least 540 degrees. Detorsion of the adnexa was performed, and separate cystic and solid masses were visualized. On aspirating fluid from the cystic mass, fimbria-like structure was observed on the surface of cystic mass suggesting that the cystic mass was a hematosalpinx and the solid mass, an enlarged ovary. A band-like tissue was connected the solid ovary to the fimbria. A left salpingectomy was performed because of ischemic, irreversible changes in the enlarged left fallopian tube. Considering the young age of the patient and the weak contrast effect seen in CT, the ovary was preserved. The total duration of the procedure was 1?h and 49?min, and total blood loss was 300?ml (including bloody ascites during laparoscopy). After surgery, her symptoms (abdominal pain and nausea) disappeared quickly. Laboratory tests showed a rapid decrease in inflammatory markers. On the fifth postoperative day, the left ovary measured 62 × 36?mm, and the patient was discharged on the same day. On the 28th postoperative day, physical examination was unremarkable, and the left ovary had shrunk to 35 × 29?mm in size.

Grossly, the cyst was unilocular, filled with blood, and had no obvious mass lesion. Microscopically, extensive necrosis and congestion of the cyst wall with some preserved fallopian tube epithelium were observed. Hence, a definitive diagnosis of fallopian tube hematoma due to adnexal torsion was made.