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Haemorrhagic Fimbrial Cyst Leading To Fallopian Tube Torsion In A Young Girl-Successful Laparoscopic Detorsion And Tubal Preservation

Ramnik Patel¹, Indranil Dutta², Rani Prajwala², Janet Cresswell²
¹Department of Paediatric Urology, UCLH and GOSH, London
²Department of Obstetrics and Gynaecology, Chesterfield Royal Hospital, United Kingdom

 

Abstract

A case of left fimbrial cyst (para ovarian cyst which was haemorrhagic) leading to fallopian tube torsion in an 18-year-old girl, who presented with 6 days of left iliac fossa and suprapubic pain and who had features of a 4.6 cm simple cyst on ultrasound scan. At laparoscopy the diagnosis was confirmed and underwent successful detorsion of fallopian tube with cystectomy and preservation of the left fallopian tube. In the presence of symptoms, even a smaller than 5 cm cyst should be considered to be torted and prompt action may allow for the preservation of the tube and /or ovary. Laparoscopy allowed her to go home on the same day and pain had disappeared instantaneously. Although fallopian tube torsion is rare, it should be considered in patients presenting with acute abdomen. Early diagnosis and timely laparoscopic intervention are vital to preservation of the fallopian tube and relief of symptoms.

Key words: fimbrial cyst, fallopian tube, torsion, adolescent, laparoscopy, fallopian tube preservation, fertility Introduction

 

Correspondence

Ramnik Patel
Department of Paediatric Urology
University College London Hospitals and
Great Ormond Street Children’s Hospital NHS Foundation Trust
London, United Kingdom
Phone: 00447956896641,
Fax: 00441162586089
E mail: This email address is being protected from spambots. You need JavaScript enabled to view it. , This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Torsion of the fallopian tube and the fimbrial cyst is not only an exceptional event but a significant cause of sudden and severe lower abdominal pain in females that is difficult to diagnose before intervention[1-7]. We wish to present a rare case in which detorsion and fimbrial cystectomy procedure was successfully carried out laparoscopically with preservation of the fallopian tube.

Case report

An 18-year-old presented in the accident and emergency department with acute abdominal pain in the left iliac fossa and suprapubic region of 6 days duration. She had constipation for 3 days. She was not sexually active. Her menstrual cycles were regular and her last menstrual period was 3 weeks prior to admission. She was in agonizing pain and required intravenous morphine. She was apyrexial with stable observations but was quite tender in the left lower abdomen and in the suprapubic region. She was otherwise fit and well and had a background history of hirsutism which was extensively investigated 2 years previously.

Urine dipstick, microscopy and culture were normal. Haemoglobin was 134 g/L; white cell count 6.7 x109/L, neutrophils 4.6 x109/L, platelets 237 x109/l and her renal and liver functions were within normal levels. Vaginal swabs were normal. All hormonal assays done earlier including LH, FSH, 17 hydroxyprogesterone, testosterone, androstenedione and DHEA sulphate were normal but sex hormone binding globulin was 18 nmol/L (45-155).

Ultrasound scan showed normal anteverted uterus with normal endometrium. It showed a 54mm x 46mm x 45mm simple cyst within the pouch of Douglas which appeared to originate from the left ovary. Right ovary was normal. There was trace of free fluid in pelvis. No abnormality was seen in gall bladder, biliary tree, liver, pancreas, spleen or kidneys. Urinary bladder was smooth walled and normal. (Fig.1)

Figure 1. USS showing cyst in the Pouch of Douglas

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Ovarian cyst with haemorrhage, rupture or torsion was considered in the differential diagnosis. At laparoscopy, uterus and both ovaries were normal. Right fallopian tube was normal. Left fallopian tube showed three and half turns torsion due to a haemorrhagic fimbrial cyst. (Fig.2) She underwent detorsion with preservation of the fallopian tube and fimbrial cystectomy was carried out uneventfully and she was discharged home the same day. (Fig.3)

Figure 2. Laparoscopic findings: A. Three and half turn of fallopian tube and fimbrial cyst torsion, B Normal proximal fallopian tube. C Haemorrhage and ischemic effects of the torted fimbrial cyst. D. Cystectomy in progress

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Figure 3. Laparoscopic procedures: A. Detorsion of the fallopian tube and total excision of fimbrial cyst B. Excised fimbrial cyst. C. Right ovary with fallopian tube. D. left ovary with preservation of the fallopian tube.

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Macroscopic examination of the excised cyst showed a haemorrhagic unilocular cystic structure 55x25x8mm in size with a single area of full thickness rupture up to 10mm in diameter. The internal and external surfaces of the cyst were smooth. The histopathological examination showed features consistent a benign fimbrial cyst. There was no evidence of epithelial atypia or dysplasia within the simple surface epithelial lining. The cyst wall showed features of secondary ischaemic change due to torsion. There was no evidence of endometriosis. No fallopian tube tissue was present. It was concluded to be a left fimbrial cyst -benign fimbrial (paratubal) type cyst. There was evidence of ischaemia and haemorrhage but no evidence of neoplasia. The post-operative period was unremarkable and at 1-year follow-up, she is well and asymptomatic.

Discussion

Torsion of fallopian tube together with fimbrial cyst is a very rare coexistent lesion in the same patient. It is seen in adults and its occurrence in an adolescent virgin girl is seen occasionally [2-3]. Instead of the fimbrial cyst, a hydrosalpinx can present with similar clinical picture as reported earlier [4-5]. Torsion of para-ovarian cyst may have similar presentation [6]. Isolated fallopian tube torsion without a cyst is another lesion which may be difficult to suspect as there is no cyst on ultrasound [7]. Most cases present with acute abdomen and if not treated early can lead to secondary changes and preservation of the tube and cyst excision becomes difficult as time passes. As the ultrasound showed simple cyst less than 5 cm in diameter, it could not get theatre priority.

Preoperative diagnosis is not possible as it has no pathognomic symptoms, clinical findings on physical examination and any particular laboratory or imaging diagnostic characteristics. Torsion of fallopian tube in association with fimbrial cyst should be considered presenting with acute pelvic pain even if the ultrasound shows simple cyst less than 5 cm in diameter, and prompt laparoscopy can preserve the tube and thus fertility. It is an uncommon emergency event and a difficult condition to evaluate clinically and diagnose pre-operatively. All cases presented like that should be referred to gynaecology rather than general surgery especially with left iliac fossa pain.

Traditional approach is emergency laparotomy and most cases as late as our case will have salpingectomy due to late intervention. However, laparoscopy has not only revolutionised diagnosis but therapeutic intervention is possible with experienced laparoscopic team. Delay in diagnosis and intervention is inevitable due to the factors mentioned above.

Conclusion

In conclusion, we believe that laparoscopy is diagnostic and therapeutic, very cosmetic, safe, effective and allows faster recovery and it should be the modality of choice especially in young adolescent patients whenever possible. Fimbrial cyst with fallopian tube torsion is a very rare combination of lesions and should be considered in differential diagnosis of acute abdomen in an adolescent girl. Left iliac fossa pain and tenderness suggests gy-naecological pathology rather than appendicitis and shift to suprapubic area may suggest its location to the pouch of Douglas. Pre-operative diagnosis is rare and laparoscopy should be considered promptly. Whenever possible detorsion and preservation of the tube and cystectomy should be performed in view of fertility implications. Laparoscopy is cosmetic, less painful, leads to faster recovery and is safe and effective.

Conflict of Interest: None

 

 

References

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