Hyde Hannah,  Tutman Jeffrey,  Blanco Ernesto

Final Pr. ID: Poster #: CR-015

Ovarian torsion is a very rare occurrence where the ovary becomes twisted, cutting off blood supply, and placing the ovary at risk of tissue death and loss of function. Appendicitis, although more common in the pediatric population, is still a relatively uncommon condition that can have grave consequences. Appendicitis secondary to ovarian torsion, in the instance where the ovary twists on its peduncle around the body of the appendix, is not only extremely rare, but puts the patient at risks for complications and consequences for both of these rare issues. This case report will tell the story of a 15-year-old girl including her initial presentation, clinical details, imaging, post-operative notes, and prognosis. Although a very atypical finding, this case highlights the importance of time and the particular dangers when dealing with two very critical diagnoses. Read More

Authors:  Hyde Hannah , Tutman Jeffrey , Blanco Ernesto

Keywords:  Appendicitis, Torsion, Ovary

Gonzalez Veronica,  Aupy Ariane,  Lulkin Solange

Final Pr. ID: Poster #: CR-007 (S)

Introduction: Accessory spleen is an abnormality represented by ectopic splenic tissue detached from the main body of the spleen. Torsion is a possible complication and it occurs exceptionally. Clinically it is characterized by a nonspecific acute or recurrent abdominal pain.
Case: A 12 years old female with recurrent abdominal pain and palpable mass on her left iliac fossa, that has been noticed a month before consultation. At the emergency service she was checked and complementary exams were requested.
US: In the left iliac fossa it was found a solid, rounded formation, with well-defined edges, which moved when the patient changed her position. It showed positive Doppler examination except for a focal hypoechogenic area, which was not vascularized. The structure reminded the spleen echogenicity.
CT: normal spleen parenchyma, shape and edges. At left iliac fossa, next to the lower pole of the kidney, a rounded well-defined image which showed heterogeneous EV enhancement with no opacification of the lower corner due to ischemia areas was seen. This image had a vascular hilum that connected to the main spleen vascular hilum. Further images where taken changing the patient position, where the movement of the mass was corroborated.
As a result of this exams we realized that the recurrent abdominal pain of the girl was due to an ectopic spleen that has been torsioned - detorsioned several times.
Conclusions: Usually, accessory spleen is asymptomatic. Torsion and infarction, rupture with bleeding, and infection with abscess are a very rare complications. Intermittent torsion-detorsion may produce recurrent episodes of abdominal pain caused by short-lasting ischemia of the accessory spleen or from direct mechanical irritation of surrounding organs.
To sum up, torsion of an accessory spleen is extremely rare and is still a diagnostic dilemma. So we should consider this any time a patient with abdominal pain (acute or recurrent) comes to us and other diagnosis failed to explain it. Read More

Authors:  Gonzalez Veronica , Aupy Ariane , Lulkin Solange

Keywords:  spleen, accesory, torsion

Mchendrie Mariska,  Rasheed Shabana

Final Pr. ID: Poster #: EDU-049

The purpose of this article is to review some of the different causes of scrotal pain in the pediatric population. In the acute setting, the most common cause of testicular pain is testicular torsion, however, the causative etiologies are broad. These include infectious, inflammatory, traumatic, referred pain, idiopathic or chronic causes. Sonography is the imaging modality of choice for the evaluation of scrotal pain in children. We will present various causes of scrotal pain in children, apart from testicular torsion and demonstrate comprehensive ultrasound features of each. Accurate differentiation and a definitive diagnosis without delay, is crucial for the proper management and favourable outcome of the patient. Read More

Authors:  Mchendrie Mariska , Rasheed Shabana

Keywords:  Scrotal Pain, Torsion, Other causes

Veale Simone,  Choudhary Arabinda,  Kecskemethy Heidi,  Gould Sharon

Final Pr. ID: Poster #: SCI-013

This retrospective pilot study was performed to assess the utility of limited protocol MRI for appendicitis in excluding ovarian torsion by assessing ovarian symmetry with regard to size and appearance comparing torsed cases to controls. Read More

Authors:  Veale Simone , Choudhary Arabinda , Kecskemethy Heidi , Gould Sharon

Keywords:  Ovary, Torsion, MRI

Otjen Jeffrey,  Stanescu A. Luana,  Ansdell David,  Alessio Adam,  Parisi Marguerite

Final Pr. ID: Poster #: SCI-023

Pelvic ultrasound is commonly used to detect ovarian torsion, but the diagnosis remains challenging as there is no single pathognomonic feature. This retrospective case-controlled study aims to identify an algorithm to detect torsion based on common ultrasound imaging features. Read More

Authors:  Otjen Jeffrey , Stanescu A. Luana , Ansdell David , Alessio Adam , Parisi Marguerite

Keywords:  torsion, ultrasound, machine learning

Horak Richard,  Mega James,  Tanton Phillip,  Criman Erik,  Tabak Benjamin,  Rooks Veronica

Final Pr. ID: Poster #: CR-006

Fatty falciform ligament appendage torsion (FFLAT) is a rare phenomenon as there are only two reported pediatric cases of falciform ligament fatty appendage torsion in the literature. In this case, the diagnosis was established via ultrasound (US) and confirmed with computed tomography (CT). US showed an echogenic, ill-defined mass in the epigastric region that extending into the falciform ligament. CT showed the “hyperattenuating rim” sign. This report is the first reported female pediatric case of FFLAT that was diagnosed with US and CT, given a trial of analgesics, and definitively cured via minimally invasive surgical excision.

A 13-year-old female presented to the emergency department with episodic waxing and waning abdominal pain for three days. The pain had localized to the mid-epigastrium and worsened with deep inspiration. On examination, vital signs were within normal limits. Focal tenderness was elicited upon palpation of the epigastrium. Laboratory evaluation revealed a mild leukocytosis 14.2 x 109/L, normal range (3.9-10.6 x 109/L).
Read More

Authors:  Horak Richard , Mega James , Tanton Phillip , Criman Erik , Tabak Benjamin , Rooks Veronica

Keywords:  Torsion, Falciform ligament, Fatty appendage torsion

Cielma Tara,  Adeyiga Adebunmi,  Bandarkar Anjum

Final Pr. ID: Poster #: EDU-022

Adnexal torsion is one of the most common gynecologic surgical emergencies. Delayed diagnosis could result in tissue necrosis, leading to loss of ovarian function and impaired fertility.

The goals of this exhibit are:
1. Review the anatomy of the female pelvis.
2. Discuss the incidence, risk factors, and clinical characteristics of adnexal torsion.
3. Describe the technical approach of performing pelvic ultrasound.
4. Illustrate the sonographic imaging spectrum of adnexal torsion.
5. Discuss diagnostic criteria of adnexal torsion. Read More

Authors:  Cielma Tara , Adeyiga Adebunmi , Bandarkar Anjum

Keywords:  adnexal torsion, ovarian torsion, fallopian tube

Aboughalia Hassan,  Oztek Murat Alp,  Noda Sakura

Final Pr. ID: Poster #: EDU-008

A whirlpool describes rotating water created by opposing currents or upon an encounter with an obstacle. On imaging, it refers to a twist of the vascular pedicle of an organ, with a subsequent characteristic appearance on color Doppler images. Multiple abdominal pediatric emergencies are associated with a whirlpool sign, including midgut and other intestinal volvulus, testicular torsion, and ovarian torsion. This exhibit aims to review the underlying embryologic mechanism predisposing to this characteristic appearance, the role of this sign in the diagnosis of these conditions, the supporting imaging features that can help further define the diagnosis, as well as some pitfalls and differential diagnoses that can lead to a fallacious diagnosis. Read More

Authors:  Aboughalia Hassan , Oztek Murat Alp , Noda Sakura

Keywords:  Whirlpool sign, Midgut malrotation, Testicular torsion

Otjen Jeffrey,  Stanescu A. Luana,  Parisi Marguerite

Final Pr. ID: Poster #: SCI-052

Ovarian torsion in pediatrics is challenging to diagnose, both clinically and radiologically. Ultrasound is most commonly used to evaluate for this process, though there are no sonographic findings that are pathognomonic. One sonographic finding that has been infrequently reported in the literature is medialization of the ovary (defined as the ovary at or crossing the midline of the uterus), as the adnexal structures are drawn inwards by the twisted broad ligament. Knowledge of this finding in addition to the other more classic findings of torsion can be an important clue to the diagnosis. This study evaluates the presence of ovarian medialization in a large number of cases of known torsion. Read More

Authors:  Otjen Jeffrey , Stanescu A. Luana , Parisi Marguerite

Keywords:  Medialization, Ovary, Torsion, Ultrasound

Jackson Dana,  Gould Sharon,  Choudhary Arabinda,  Epelman Monica

Final Pr. ID: Poster #: EDU-082

Acute onset pelvic pain in a pubertal girl has many possible etiologies. Reproductive, urinary and gastrointestinal pathology all can underlie acute onset pelvic pain in this age group and may have similar presentations. We present a series of six cases in which MRI was utilized for further evaluation of US findings and either confirmed the need for surgical intervention, or established the cause of pain and eliminated the need for surgery. Read More

Authors:  Jackson Dana , Gould Sharon , Choudhary Arabinda , Epelman Monica

Keywords:  Pelvic pain, Ovarian torsion, Appendicitis

Dahmoush Hisham,  Chauvin Nancy

Final Pr. ID: Poster #: SCI-046

Massive ovarian edema (MOE) is a rare benign condition that affects childbearing women including girls. MOE is thought to result from intermittent or partial torsion of the ovary compromising the venous and lymphatic drainage but with preserved arterial supply. The clinical features of MOE are nonspecific and can simulate tumors, frequently resulting in oopherectomy. Fertility-sparing surgery may be undertaken if the diagnosis is considered prospectively and intraoperatively with a wedge biopsy, avoiding unnecessary resection of the affected ovary. We present clinical presentations and imaging features that should alert pediatric radiologists to the diagnosis of MOE. Read More

Authors:  Dahmoush Hisham , Chauvin Nancy

Keywords:  ovarian, torsion, tumor, edema

Stanescu A. Luana,  Otjen Jeffrey,  Parisi Marguerite

Final Pr. ID: Poster #: SCI-075

Purpose
Ovarian torsion is rare in neonates and infants. Clinical diagnosis is challenging in the setting of lack of specific symptoms and the limitations in assessing pain in infants. Torsed ovaries in this patient population are also a diagnostic dilemma on imaging. In this study we reviewed the spectrum of imaging findings with pathologic correlation in a large series of patients. Read More

Authors:  Stanescu A. Luana , Otjen Jeffrey , Parisi Marguerite

Keywords:  Neonatal, infantile, Ovarian Torsion

Dorai Raju Anand,  Chauhan Ankita,  Cohen Harris

Final Pr. ID: Poster #: EDU-027

Adnexal torsion is the most common gynecological emergency in children and adolescents. Early diagnosis is crucial. The diagnosis of torsion requires a summation analysis of clinical, laboratory, and imaging findings. Adnexal torsion may mimic abnormalities of the gynecological (such as ectopic pregnancy and pelvic inflammatory diseases ), genito-urinary (such as renal or ureteric stones), and gastrointestinal tract abnormalities (mostly, appendicitis and inflammatory bowel disease like Crohn's). Gastrointestinal causes mimicking torsion may also include less likely abnormalities of the upper GI tract, including liver, gall bladder, pancreatic, and ulcer disease. Additionally, rare tumor masses may be a direct cause of ovarian or para-ovarian torsion or may simulate the pain.

We present a spectrum of imaging cases showing simulators of ovarian torsion as well as a spectrum of actual gynecological system torsions, including those of the ovaries and para-ovarian structures in the pediatric population. We review the fundamental potential diagnostic pitfalls that may falsely suggest an adnexal torsion as well as imaging features to help evaluate adnexal and para-adnexal torsion.

Imaging plays a critical role in the diagnosis of adnexal torsion and its simulators. We demonstrate imaging findings of those simulators as well as in adnexal torsion. Our study emphasizes primarily on the use of ultrasound to postulate key imaging points.

Adnexal torsion can take a subacute, intermittent, or chronic course, which may be challenging to diagnose. Prompt early recognition and operative management of this abnormality is essential. Correct and early diagnosis facilitates prompt surgical exploration to prevent ovarian tissue loss and the consequent effect on future fertility.
Read More

Authors:  Dorai Raju Anand , Chauhan Ankita , Cohen Harris

Keywords:  Torsion, Adnexa, ovary, fallopian tube

Karakas S Pinar,  Udayasankar Unni,  Park Ellen S,  Kammen Bamidele,  Su Wendy,  Kim Sunghoon,  Hui Thomas,  Chung Taylor

Final Pr. ID: Poster #: EDU-035

Adnexal torsion is a common emergency room query in young girls and teenagers presenting with pelvic pain. It is a consequence of an underlying adnexal lesion or to anatomical laxity of the suspensory/anchoring ligaments. Clinical symptoms at presentation can be confusing and nonspecific, yet prompt diagnosis and surgical intervention are essential to save the adnexa. Radiology plays a crucial role in the diagnosis of adnexal torsion. Our exhibit will review and promote the rapid MRI as the first line, one-stop imaging in the diagnosis of adnexal torsion and other causes of pelvic pain. Some cases will be presented with initial ultrasound images and demonstrate how MRI increased the confidence in the diagnosis. All presented cases have pathology correlation and or operative reports and follow-up imaging. We will show various cases of ovarian and tubal torsions and their mimickers. In particular, we include torsions due to anatomical laxity of the suspensory ligaments, resulting from tubo-ovarian cysts and solid adnexal masses as well as cases of isolated tubal torsions.

Table of Contents/Outline:

Review of the embryology and anatomy of adnexa including suspensory/ anchoring ligaments.
Review pathophysiology and progression of ovarian torsion
Review rapid motion insensitive high-resolution MRI protocol for adnexal torsion
Review hallmark imaging findings of adnexal torsion with MRI (with accompanying ultrasound comparison in some cases)
Review MRI findings of adnexal viability and demise
Review multiple MRI examples of adnexal torsion and its mimickers Read More

Authors:  Karakas S Pinar , Udayasankar Unni , Park Ellen S , Kammen Bamidele , Su Wendy , Kim Sunghoon , Hui Thomas , Chung Taylor

Keywords:  Adnexal Torsion, Tubal Torsion, Rapid MRI

Dorai Raju Anand,  Chauhan Ankita,  Cohen Harris

Final Pr. ID: Poster #: CR-016

Isolated bilateral fallopian tube cyst torsion is extremely rare in the pediatric population. We have found no published reports of this entity in a child. Early diagnosis of such cases is crucial for the possibility of fallopian tube salvage surgery and the prevention of irreversible damage. Nonspecific clinical and imaging findings in a few reported unilateral cases in children often make surgical intervention mandatory for the diagnosis.

A 10-year-old girl came to the hospital for acute lower abdominal pain. Ultrasound findings demonstrated two large para-ovarian cysts, contiguous with tortuous and dilated fallopian tubes, suggesting torsion of the tubes. A clinician ordered CT did not add any new information.
The patient underwent a diagnostic laparoscopy that confirms the USG impression of the torsion of the bilateral fallopian tubes. Surgical exploration demonstrated twisting of about 1080 degrees of the hemorrhagic and necrotic right paratubal cyst and tube. The left cyst and tube were torsed at 360 degrees. Right partial salpingectomy, left paratubal cyst aspiration, and detorsion of fallopian tubes was accomplished. The uterus and ovaries were healthy.

Isolated bilateral fallopian tube torsion is extremely rare in the pediatric population with nonspecific clinical and imaging findings. Diagnosis usually requires surgery. Our study showed a case of bilateral fallopian tube torsion that occurred about bilateral paratubal cysts. Visualization of a dilated fallopian tube in the presence of normal-sized ovaries must be concerning for fallopian tube torsion, which can be secondary to a paratubal mass or cyst. Prompt early recognition and operative management of this relatively rare entity may prevent unnecessary tubal resection and improve long term fertility. Read More

Authors:  Dorai Raju Anand , Chauhan Ankita , Cohen Harris

Keywords:  Torsion, Fallopian tube, Paratubal cysts

Sintim-damoa Akosua,  Sandhu Preet

Final Pr. ID: Poster #: EDU-118

There is a wide spectrum of scrotal pathology in the pediatric population ranging from the benign to those requiring emergent intervention. Ultrasound is widely available, relatively low cost, and provides superior imaging of the scrotum. In addition, ultrasound has the added benefit of no ionizing radiation. Scrotal pathology may be vascular, traumatic, embryologic, or neoplastic in origin and may arise from abnormalities inherent to the scrotum or gastrointestinal or hematological in nature. Testicular torsion is the underlying cause of acute scrotum in up to 26% of pediatric patients. It is important to differentiate acute torsion from late torsion, intermittent torsion, and torsion of the appendix testis on ultrasound. Trauma involving the scrotum can result in scrotal hematoma or testicular fracture. Infectious etiologies of scrotal pathology may include epididymitis and orchitis with or without an associated pyocele. A variety of masses may be seen in the testicle including epidermoid cyst, congenital adrenal rest, germ cell tumor, and lymphoma. Ultrasound along with pertinent clinical history can be helpful in narrowing the differential diagnosis.
Read More

Authors:  Sintim-damoa Akosua , Sandhu Preet

Keywords:  scrotum, torsion

Sinayuk Boris,  Swenson David,  Herliczek Thaddeus,  Wallach Michael,  Cassese John

Final Pr. ID: Poster #: EDU-054

1. Highlight recent literature on ultrasound (US) imaging of the spermatic cord for testicular torsion.
2. Present illustrative cases of testicular torsion from our institution that demonstrate the spectrum of US findings, highlighting the importance of evaluating the spermatic cord and how relying solely on grayscale US and doppler of the testicle itself can be misleading in the setting of torsion.
3. Encourage real-time US evaluation of the spermatic cord in all suspected cases of testicular torsion. Read More

Authors:  Sinayuk Boris , Swenson David , Herliczek Thaddeus , Wallach Michael , Cassese John

Keywords:  testicular torsion, ultrasound, spermatic cord

Stanescu Arta,  Otjen Jeffrey,  Parisi Marguerite

Final Pr. ID: Paper #: 003

Fallopian tube torsion is a rare cause of acute abdominal pain in pediatric patients. Pelvic ultrasound is the first imaging modality utilized to evaluate for pelvic pathology, typically to rule out ovarian torsion. Ultrasound findings of fallopian tube torsion can be challenging, leading to delayed surgical intervention, particularly when ovaries have a normal gray scale appearance and spectral Doppler waveforms. We reviewed the ultrasound features of fallopian tube torsion in a series of surgically proven cases. Read More

Authors:  Stanescu Arta , Otjen Jeffrey , Parisi Marguerite

Keywords:  Fallopian tube, torsion, ultrasound

Oliver Brianna

Final Pr. ID: Poster #: EDU-036

Pelvic and scrotal pain are common emergent presenting symptoms in the pediatric population, and these patients are commonly imaged to evaluated for gonadal torsion. In this educational exhibit we will review the entire spectrum of gonadal and paragonadal torsions in the pediatric population, focusing on clinical presentations, key imaging findings, possible pitfalls in diagnosis, and next steps in management. It is essential for the pediatric radiologist to be familiar with this range of pathology in order to render an accurate and timely diagnosis, particularly given that some (but not all) of these diagnoses require emergent surgery. Read More

Authors:  Oliver Brianna

Keywords:  Torsion, Emergencies, Pelvic

Sundaram Karthik,  Singh Sudha,  Hernanz-schulman Marta

Final Pr. ID: Poster #: EDU-027

Introduction

Torsion or volvulus of upper abdominal viscera is rare and related to incomplete development and laxity of suspensory ligaments, or to poorly developed supernumerary accessory lobes. Clinical symptoms at presentation can be confusing and nonspecific, yet prompt recognition is essential to avoid life-threatening complications. Radiologists play an essential role in prompt recognition of these conditions. Our exhibit will review congenital anomalies of upper abdominal solid viscera that can lead to volvulus within an embryologic and anatomic framework. As examples, we include cases of mesenteroaxial gastric volvulus (Figure 1), torsion of an accessory hepatic lobe (Figure 2), and splenic torsion in the setting of polysplenia (Figure 3). Our cases include radiologic-pathologic correlations and therapeutic implications of solid visceral torsions.

Table of Contents/Outline:

Review of the embryology and anatomy of upper abdominal organs including a detailed pictorial of suspensory and anchoring ligaments.
Review and examples of types of gastric volvulus and treatment.

Review of variants of liver anatomy and of incidence and location of accessory hepatic lobes, with examples.

Review of splenic anatomy and normal variants, splenic torsion and gross malformations including variants seen in heterotaxy, with review of treatment options in splenic torsion, including observation, surgical pexy or resection.

Review of associated congenital anomalies (e.g. omphalocele, diaphragmatic hernia, and malrotation, etc.) Read More

Authors:  Sundaram Karthik , Singh Sudha , Hernanz-schulman Marta

Keywords:  Torsion, Volvulus, Abdominal