Ovarian cyst torsion in a pre-menopausal woman causing intestinal obstruction: a case report

Intestinal obstruction due to adnexal torsion is a rare complication that can be occurred during torsion of an ovarian cyst. A premenopausal woman presented to the emergency department with complaints of abdominal distension, abdominal pain, and obstipation for 2 days. An abdominal radiograph showed signs of large bowel partial obstruction. Hence admission to the surgical department was ordered. Due to deterioration of the patient, a gynaecological evaluation took place. Ultrasonography demonstrated a large ovarian cyst, which was also confirmed by an abdominal computed tomography scan and thus immediate laparotomy was decided. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed due to torsion of a giant ovarian cyst, which caused intestinal obstruction by compression. The post-operative course of the patient was uneventful. Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction.


Introduction
Ovarian torsion is caused by rotation of the ovary or adnexa with the vascular pedicle on its axes resulting in venous and arterial obstruction [1].Torsion of the right adnexa occurs more commonly due to hypermobility of the right uteroovarian ligament which is longer than the left.The majority of the patients present with abdominal pain, fever vomiting and/or nausea.These nonspecific symptoms may lead to delayed diagnosis and physicians may face a diagnostic dilemma.In spite of being only 2.7% of acute gynaecological conditions [2], ovarian torsion requires immediate surgery.We hereby report a case of an ovarian cyst torsion causing partial intestinal obstruction.

Patient and observation
Patient information: a 47-year-old woman presented to the emergency department with complaints of abdominal distension, abdominal pain and obstipation for 2 days.She also had a history of nausea but no vomiting.She had not visited a gynecologist for annual examination in the past 2 years due to the severe COVID-19 outbreak.
Clinical findings: on examination, she was wellbuilt with blood pressure of 110/63 mmHg, pulse rate of 98 bpm and her body temperature was normal.She had mildly distended abdomen though was diffuse tenderness and a mass in her left iliac fossa and suprapubic region.Bowel sounds were present.A digital rectal examination revealed fecal staining in the rectum.Timeline of current episode: an abdominal radiograph showed signs of large bowel partial obstruction.The patient was given 30 ml of gastrografin gastroenteral solution; on the radiograph, the gastrografin appeared to be present in the rectum along with air-fluid levels (Figure 1).

Diagnostic
assessment: routine blood investigations revealed normal leukocyte counts of about 8000 cells/mm 3 and an elevated C-reactive protein level of 159 mg/L.
Diagnosis: admission in the surgical department was ordered, and the patient was treated over intestinal obstruction with intravenous fluids and antibiotics.Due to deterioration of the patient´s symptoms, a gynaecological evaluation took place.Both transabdominal and transvaginal ultrasonography demonstrated a large ovarian cyst of 11.8x6 cm with thick walls but no septation, which was also confirmed by an abdominal computed tomography scan that was carried out (Figure 2).Therapeutic interventions: a decision for laparotomy was made, after informed consent.Intraoperative findings include a huge infracted, torted left ovarian cyst, adherent to the sigmoid hence causing partial intestinal obstruction by compression.The cyst was removed and an abdominal hysterectomy with bilateral salpingooophorectomy was carried out due to two big fibroids that were found during the transvaginal ultrasound (Figure 3).

Follow-up and outcome of interventions:
postoperative ileus was settled on post-operative day 2, so oral feeding was started on day 4 and the patient was discharged after 5 days overall.Histopathology of the specimen revealed a follicular cyst with necrosis due to torsion measuring 12.5 cm.Patient perspective: "I thought that the abdominal pain and the constipation was a digestive disease.I felt quite stressed when I heard about the computerized tomography (CT) findings.I should have never skipped my annual gynecologic examination, due to the pandemic.Fortunately, everything worked out in the end." Informed consent: written informed consent was obtained from the patient.

Discussion
Ovarian cysts with a diameter of at least 10 cm may cause abdominal pain, swelling and vaginal bleeding [3].Simple ovarian cysts are the most common non neoplastic adnexal masses among women of reproductive age [2,3].Ovarian torsion can happen if an ovarian mass or cyst rotates the uteroovarian and the infundibulopelvic ligament and is rarer on the left side [1].Intestinal obstruction due to ovarian torsion is a very occasional complication of ovarian cyst [4,5] and might be present through two mechanisms; either a giant ovarian mass may compress the bowel [2] or a loop of small and/or large bowel becomes adherent to the cyst and rotates with the torsion of the cyst [4].Although ovarian torsion during pregnancy is relatively rare, adnexal torsion during pregnancy has been reported [1], as well as intestinal obstruction during pregnancy caused by bilateral ovarian cystic teratoma [6].The clinical symptoms of ovarian torsion are nonspecific such as abdominal or pelvic pain, nausea and vomiting [1], which is similar to intestinal obstruction clinical appearance; the latest includes nausea, vomiting, bloating, crampy, colicky abdominal pain and minimal or complete absence of flatus and bowel movements [4].

Conclusion
Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction.

FiguresFigure 1 :Figure 2 : 3 :Figure 1 :Figure 2 :
FiguresFigure 1: abdominal X-ray of the patient: A) on admission to the emergency department; B) after oral administration of gastrografin gastroenteral solution Figure 2: A,B,C) computerized tomography showing air-fluid levels in the small intestine and the size of the ovarian cyst Figure 3: perioperative picture showing the torted stem of the cyst in situ

Figure 3 :
Figure 3: perioperative picture showing the torted stem of the cyst in situ