Ovarian Torsion

Ovarian torsion is like the MI of the pelvis.  Sometimes all it takes is a good story to investigate.

When to worry, when to walk it off, and when to work it up:

 

What is the typical presentation of ovarian torsion?

There is none.  The presentation varies so much, we need a rule to live by:

Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise.  This includes the cases in which you are concerned about appendicitis.  They both can be fake-outs.

Often the pain is severe and abrupt, but trying to tease this out is often not fruitful.

Reported signs and symptoms associated with ovarian torsion:

Stabbing pain, 70%

Nausea and vomiting, 70%

Sudden, sharp pain in the lower abdomen, 59%

Pain radiating to the back, flank, or groin, 51%

Peritoneal signs, 3%

Fever, less than 2%

And of course…no pain on presentation…30%…intermittent torsion.

What is the mechanism of ovarian torsion?

  1. Structurally abnormal ovary (including cysts) that causes the ovary to flop over and twist on its vascular axis
  2. Hypermobile ovary with vigorous movement twists on its vascular pedicle and cuts off blood supply

The Dual Blood Supply to the Ovaries: Why Doppler Flow can Fool You

What ultrasound findings suggest ovarian torsion?

  1. The enlarged hyper- or hypo-echoic ovary from generalized edema
  2. Peripherally displaced follicles with hyperechoic central stroma (string of pearls sign): stroma is edematous, leaving the follicles to stand out
  3. A midline ovary – if the ovary magically makes it to midline, something is up
  4. Free fluid in the pelvis – this is seen in the vast majority of cases

As far as Doppler flow goes, you may see one of several scenarios:

  1. Little or no venous flow – this is very common, as we talked about, because the low pressure venous system is the first to take a hit in torsion
  2. Totally absent arterial flow – this is not as common, but totally diagnostic
  3. No flow in diastole, or reversal in flow – the red and blue of dopple does not correspond to arterial and venous.  Doppler is a vector.  Red is fluid coming towards the probe, blue is programmed to present flow away from the probe.  If you have just one or the other, then by definition there is a problem with the vascular circuit.

Other things you may see on ultrasound include focal tenderness with the probe, or the whirlpool sign – this is a twisted vascular pedicle.  

In children, is there an ovarian size (volume) that rules out torsion?”

In the Journal of Pediatric Radiology, Servaes et al. catalogued the ultrasound findings in children with surgically confirmed torsion over a 12 year period.  In this case series of 41 patients, the median age was 11.  The age range was one month old to 21 years of age.  They found that in torsed ovaries, the ovarian volume was 12 x that compared to the normal, non-torsed contralateral ovary.

That is to say, in this case series all torsed ovaries were larger than the normal contralateral ovary.

Summary

Sudden unilateral lower abdominal or pelvic pain in a female? Think torsion.

Have a low threshold for investigation.

Know the performance characteristics of ultrasound findings and involve a gynecologist early.

 

This post and podcast are dedicated to Stephanie Doniger, MD for her enthusiasm, spirit, and expertise in #MedEd #FOAMed #FOAMped #POCUS 

References

Abe M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur. J. Pediatr. Surg. 2004;14:168.

Aziz D, Davis V, Allen L, Langer J. Ovarian torsion in children: Is oophorectomy necessary? J. Pediatr. Surg. 2004;39:750-3.

Bristow RE, Nugent AC, Zahurak ML, et al. Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass. J. Adolesc. Health 2006;39:411.

Chang YJ, Yan DC, Kong MS, et al. Adnexal torsion in children. Pediatr. Emerg. Care. 2008;24:534-7.

Conforti A, Giorlandino C, Bagolan P. Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J. Pediatr. Surg. 2009;44:868; author reply 868-9.

Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics 2010;125:532-8. Epub 2010 Feb 1.

Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann. Emerg. Med. 2001;38:156-9.

Huang TY, Lau BH, Lin LW, Wang TL, Chong CF, Chen CC. Ovarian cyst torsion in a toddler. Am. J. Emerg. Med. 2009;27:632, e1-3.

Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a torsed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr. Radiol. 2002;32:586-8. Epub 2002 May 25.

Kokoska E, Keller M, Weber T. Acute ovarian torsion in children. Am. J. Surg. 2000;180:462-5.

Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion – a 15-year review. J. Pediatr. Surg. 2009;44:1212-6; discussion 1217.

Chmitt ER et al. Twist and Shout! Pediatric Ovarian Torsion Clinical Update and Case Discussion. Pediatr Emerg Care. 2013; 29(4):518-523.

Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children. Pediatr. Radiol. 2007;37:446-51. Epub 2007 Mar 15.

Valsky DV. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet. Gynecol. 2010;36:630-4.

Just Say No To (These) Drugs

Dogma often dictates routine care.

There are times when we have to attend to paradigm shifts.

An easy way to save lives?  Just say no to (these) drugs:

Codeine

Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor.

However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates.  The problem is, people vary in its metabolism from 0-15% of codeine is metabolized to morphine.

Ok, codeine is lame at best, unpredictable at worst.

True.  Unless you are hiding a genetic time bomb.

You’re an ultra-rapid metabolizer.

Some people have multiple extra copies of the DNA sequence for the CYP2D6 enzyme.  Ultra rapid metabolizers funnel a huge proportion of their codeine into morphine metabolism, resulting in a bolus of morphine, ending in apnea.

Promethazine with codeine

This combination is no better than placebo — all of the risks, with no proven benefit.  This combination is notoriously abused — as purple drank or sizzurp.  The rapper Pimp C died of this.

Speaking of cough syrups…

The AAP recommends no cough and cold preparations in children under age 6.  They have not been adequately studied in young children, and are not recommended for treating the common cold.

What then?  You gotta give me something, doctor!

Ok, Honey!

In a study in the Archives of Pediatric and Adolescent Medicine, Dr Paul and colleagues published: Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents.  They compared a buckwheat honey, honey-flavored dextromethorphan (DM) and no treatment 30 min before bed for children with upper respiratory tract infections.

Of the three, honey, dextromethorphan, and no treatment – honey scored the best for symptom improvement and cough frequency.

Over age 1?  Cough and cold?  Honey.  There is no concern about accidental overdose, parents are doing something with a proven effect, and compliance is pretty much 100% — and Grandma approves.

Dextromethorphan

No proven benefit over placebo.  Also widely abused, in pill form (“Skittles“) and/or liquid form mixed in alcoholic beverage (“robotripping“).

Alternatives to Codeine

Details in Audio:

Morphine liquid
Acetaminophen and Hydrocodone

Tramadol

Details in Audio:

Also morbidity and mortality due to ultra-rapid metabolism

Pearls and Pitfalls in Pediatric Pain

Allow the child to speak for himself whenever possible. After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you. Tell me more.”

Engage parents and communicate the plan to them. Elicit their expectations, and give them of preview of what to expect in the ED.

Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction.

Give detailed advice on how to manage pain at home. Set expectations. Let them know you understand and will help them through your good advice that will carry them through this difficult time. Patients and families often just need a plan. Map it out clearly.

And…

Just say no to: codeine, promethazine with codeine, and dextromethorphan.

 

Selected References

Dhaliwal G, Hsu D. Tramadol Ultra Rapid Metabolizers at Risk for Respiratory Depression. Pain Physician. 2016; 19(2):E361.

European Medicines Agency. Restriction on the use of codeine for pain relief in children—CMDh endorses PRAC recommendation [press release]. June 28, 2013.

FDA. Most Young Children With a Cough or Cold Don’t Need Medicine.

Hartling L et al. How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag. 2016; 2016: 5346819.

Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879-923.

Jin J. Risks of Codeine and Tramadol in Children. JAMA. 2017 Oct 17;318(15):1514. doi: 10.1001/jama.2017.13534.

Kelly LE et al. More Codeine Fatalities After Tonsillectomy in North American Children. Pediatrics. 2012; 129(5).

Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4):257–265

Orliaguet G et al. A Case of Respiratory Depression in a Child With Ultrarapid CYP2D6 Metabolism After Tramadol. Pediatrics. 2015; 135(3).

Poonai N. Analgesia for children in acute pain in the post-codeine era. Curr Pediatr Rev. 2017 Aug 28. doi: 10.2174/157339631366617082911563.1.

This post and podcast are dedicated to Bryan Hayes, PharmD for his practical approach to pharmacologic conundrums and to David Juurlink, MD, PhD for his steadfast dedication to patient safety and clinician education.  Check out Bryan’s helpful blog and clinical resource, PharmERToxGuy.  Check out David anywhere one utters the word Tra-ma-dol.

 

Just Say No To (These) Drugs

Dogma often dictates routine care.

There are times when we have to attend to paradigm shifts.

An easy way to save lives?  Just say no to (these) drugs:

Codeine

Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor.

However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates.  The problem is, people vary in its metabolism from 0-15% of codeine is metabolized to morphine.

Ok, codeine is lame at best, unpredictable at worst.

True.  Unless you are hiding a genetic time bomb.

You’re an ultra-rapid metabolizer.

Some people have multiple extra copies of the DNA sequence for the CYP2D6 enzyme.  Ultra rapid metabolizers funnel a huge proportion of their codeine into morphine metabolism, resulting in a bolus of morphine, ending in apnea.

Promethazine with codeine

This combination is no better than placebo — all of the risks, with no proven benefit.  This combination is notoriously abused — as purple drank or sizzurp.  The rapper Pimp C died of this.

Speaking of cough syrups…

The AAP recommends no cough and cold preparations in children under age 6.  They have not been adequately studied in young children, and are not recommended for treating the common cold.

What then?  You gotta give me something, doctor!

Ok, Honey!

In a study in the Archives of Pediatric and Adolescent Medicine, Dr Paul and colleagues published: Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents.  They compared a buckwheat honey, honey-flavored dextromethorphan (DM) and no treatment 30 min before bed for children with upper respiratory tract infections.

Of the three, honey, dextromethorphan, and no treatment – honey scored the best for symptom improvement and cough frequency.

Over age 1?  Cough and cold?  Honey.  There is no concern about accidental overdose, parents are doing something with a proven effect, and compliance is pretty much 100% — and Grandma approves.

Dextromethorphan

No proven benefit over placebo.  Also widely abused, in pill form (“Skittles“) and/or liquid form mixed in alcoholic beverage (“robotripping“).

Alternatives to Codeine

Details in Audio:

Morphine liquid
Acetaminophen and Hydrocodone

Tramadol

Details in Audio:

Also morbidity and mortality due to ultra-rapid metabolism

Pearls and Pitfalls in Pediatric Pain

Allow the child to speak for himself whenever possible. After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you. Tell me more.”

Engage parents and communicate the plan to them. Elicit their expectations, and give them of preview of what to expect in the ED.

Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction.

Give detailed advice on how to manage pain at home. Set expectations. Let them know you understand and will help them through your good advice that will carry them through this difficult time. Patients and families often just need a plan. Map it out clearly.

And…

Just say no to: codeine, promethazine with codeine, and dextromethorphan.

 

Selected References

Dhaliwal G, Hsu D. Tramadol Ultra Rapid Metabolizers at Risk for Respiratory Depression. Pain Physician. 2016; 19(2):E361.

European Medicines Agency. Restriction on the use of codeine for pain relief in children—CMDh endorses PRAC recommendation [press release]. June 28, 2013.

FDA. Most Young Children With a Cough or Cold Don’t Need Medicine.

Hartling L et al. How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag. 2016; 2016: 5346819.

Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879-923.

Jin J. Risks of Codeine and Tramadol in Children. JAMA. 2017 Oct 17;318(15):1514. doi: 10.1001/jama.2017.13534.

Kelly LE et al. More Codeine Fatalities After Tonsillectomy in North American Children. Pediatrics. 2012; 129(5).

Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4):257–265

Orliaguet G et al. A Case of Respiratory Depression in a Child With Ultrarapid CYP2D6 Metabolism After Tramadol. Pediatrics. 2015; 135(3).

Poonai N. Analgesia for children in acute pain in the post-codeine era. Curr Pediatr Rev. 2017 Aug 28. doi: 10.2174/157339631366617082911563.1.

This post and podcast are dedicated to Bryan Hayes, PharmD for his practical approach to pharmacologic conundrums and to David Juurlink, MD, PhD for his steadfast dedication to patient safety and clinician education.  Check out Bryan’s helpful blog and clinical resource, PharmERToxGuy.  Check out David anywhere one utters the word Tra-ma-dol.