Acute ovarian and fallopian tube auto-torsion

　　One, etiology

　　1. Congenital factors

　　(1) Long mesentery of the fallopian tube and ovary or variation in the length of the fallopian tube, with a spiral course, having the characteristic of being easily bendable.

　　(2) Underdeveloped mesentery at the distal end of the fallopian tube or excessive mobility.

　　(3) Congenital malformations of the reproductive organs, such as unilocular uterus, with both sides asymmetric, becoming a predisposing factor for adnexal torsion.

　　2. Acquired factors

　　(1) Lesions in the fallopian tube, increased weight, such as hydrosalpinx or hematosalpinx without adhesions.

　　(2) Dropout due to physiological cysts (follicular or corpus luteum cysts) in the ovary, which is prone to torsion.

　　(3) History of sterilization surgery using the Pomeroy technique (bilateral fallopian tube ligation and excision), where the free distal end of the fallopian tube is prone to torsion.

　　(4) Autonomic nervous system dysfunction, with abnormal peristalsis of the fallopian tubes.

　　3. External factors

　　(1) Pregnancy or uterine tumor, with the fundus of the uterus elevated, the appendages ascending to the abdominal cavity, and increased space for movement.

　　(2) Sudden changes in body position, such as sudden rotation or violent flipping over.

　　(3) Pelvic congestion during the premenstrual period or ovulatory phase.

　　(4) Drug-induced fallopian tube spasm.

　　All the above factors are triggers for the self-torsion of appendages. Under the combined action of one or more factors, complete and acute, irreversible torsion or incomplete and intermittent torsion can be caused.

　　Secondly, pathogenesis

　　1. After appendage torsion:Blood supply to the appendages is blocked, causing initial venous and lymphatic circulation disorders, while arterial perfusion continues, leading to appendage edema and thickening. The progression of torsion leads to intravascular thrombosis, starting with veins and eventually developing into arteries. If torsion is quickly resolved before the formation of arterial and venous thrombosis, appendage blood perfusion can quickly recover, and the organ can fully recover. If the torsion is complete and not resolved, it can rapidly progress from simple venous and lymphatic circulation disorders to arterial circulation blockage, and the fallopian tubes and ovaries can quickly turn deep black, leading to necrosis and gangrene. If treatment is not obtained, secondary infection can develop into peripancreatitis. In children, necrotic appendage torsion can be absorbed, and later, abdominal examination for other reasons may only find one side of the appendages, but the urinary system may show no abnormalities, which is an important differential diagnosis from congenital unilateral appendage agenesis. If it cannot be completely absorbed, calcification may occur.

　　2. If rotation is incomplete:Arterial perfusion is not completely occluded, leading to increased venous pressure, which can cause superficial vein rupture in the appendages, resulting in intra-abdominal hemorrhage. The surface of the ovary appears purple-red with hemorrhage, and when the ovary is incised, blood clots can be seen. Section examination can reveal the formation of hemorrhagic infarction. Sometimes, adhesions to other pelvic organs may also occur due to the degeneration of the surface tissue of the ovary. In severe cases, the ovary may become a parasitic organ.

　　3. If the torsion is incomplete:If venous return and lymphatic system circulation are blocked, but the arterial blood supply is not severely compromised, torsion can often be resolved spontaneously, and the appendages can fully recover within a few hours or a few days. However, the affected ovary may later show stromal luteinization, leading to clinical manifestations of masculinization; or excessive estrogen secretion can occur before the onset of menarche, promoting precocious puberty. Due to ovarian edema caused by incomplete torsion, severe cases may also be accompanied by Meig syndrome (ascites and pleural effusion).

　　1. If torsion persists and is not treated in a timely manner, there may be a slight increase in body temperature. The occurrence of necrosis and secondary infection can lead to high fever, accompanied by chills and intensified abdominal pain. Abdominal examination: muscle tension, tenderness, deep pressure on the lower abdomen on the affected side can cause pain, and post-infection can lead to rebound pain.

　　2. Bimanual examination: In normal cases of appendage torsion, the mass may not be palpable, but significant tenderness in the appendage area can be detected. In severe cases, tissue necrosis and secondary infection may occur.

　　According to clinical manifestations, appendage torsion can be classified into complete and partial torsion:

　　1. Complete torsion presents as an acute condition, with a sudden onset of severe, sharp abdominal pain, often occurring after abrupt changes in body position, such as rotation or flipping over. It usually occurs unilaterally, with a higher incidence on the right side (3:2). It is possible that the sigmoid colon on the left side limits the movement of the appendages, while the cecum and terminal ileum on the right side have a relatively greater degree of mobility, providing more room for movement of the appendages. Some patients may have a history of similar pain episodes, possibly due to a previous torsion that was spontaneously untwisted, resulting in the symptoms automatically disappearing.

　　2. The severity of unilateral abdominal pain is proportional to the degree of blood flow obstruction and the extent of edema that occurs simultaneously, and it is accompanied by rapid onset of nausea and vomiting. If the torsion at the initial stage is complete, venous return is quickly and completely blocked, resulting in simultaneous acute abdominal pain and nausea and vomiting. If the degree of torsion is mild, it may sometimes untwist itself, and the pain will disappear spontaneously, but there is a possibility of recurrence. The pain of this intermittent torsion is also intermittent, and the interval time varies depending on the frequency of发作, ranging from a few hours, days to several months. Initially, the pain is usually in the lower abdomen or pelvic pain or iliac fossa, and can also radiate to the thigh or back (the skin area innervated by T10), Lomano (1974) analyzed the pain conditions of 42 patients with adnexal torsion: 62% of the patients experienced gradually increasing pain, 38% had sudden onset. Nichols (1985) reported that 10% of the patients had chronic abdominal pain with intermittent exacerbation, which is assumed to be recurrent torsion, with symptoms alleviating or disappearing during the intervals.

　　3. If there is a corpus luteum in the ovary before torsion, the hormone concentration will suddenly drop after torsion, followed by the occurrence of withdrawalal uterine bleeding. At this time, it is necessary to differentiate from ectopic pregnancy.

　　4. If torsion persists and is not treated in a timely manner, there may be a slight increase in body temperature. The occurrence of necrosis and secondary infection can lead to high fever, accompanied by chills, exacerbation of abdominal pain, and abdominal examination: abdominal muscle tension, tenderness, deep pressure on the affected lower abdomen causes tenderness. After secondary infection, there is rebound tenderness. Bimanual examination: It may not be possible to palpate a mass in normal adnexal torsion, but significant tenderness in the adnexal area can be found.

　　Ovarian or fallopian tube torsion in normal conditions is relatively rare, generally occurring only in children and related to congenital developmental abnormalities:

　　Prevention: actively treat fallopian tube and uterine lesions to prevent torsion from occurring. Once the diagnosis is confirmed, surgery should be performed immediately. Appropriate treatment should be carried out based on the condition of the fallopian tube and ovary found during surgery. If the blood supply to the ischemic area is restored and the tissue is basically intact, conservative treatment should be provided.

　　Patients with adnexal torsion complicated with necrosis and infection may have an increased white blood cell count and neutrophils:

　　B-ultrasound examination shows enlargement of the adnexa, with no specific mass image. Doppler ultrasound detection of ovarian blood flow velocity can clearly diagnose the condition.

　　In terms of diet, it is recommended to consume more foods that promote blood circulation and dissolve blood stasis, such as hawthorn, vinegar, rose, tangerine, rapeseed, papaya, etc. The diet should be light and not include foods that generate heat, such as mutton, shrimp, crab, eel, salted fish, and black fish. It is advisable to eat lean meat, chicken, eggs, quail eggs, crucian carp, turtle, white fish, cabbage, asparagus, celery, spinach, cucumber, winter melon, mushrooms, tofu, seaweed, edible kelp, and fruits, etc.

　　1. Traditional Chinese Medicine Treatment Methods

　　1. Treatment Method: Activate blood circulation and remove blood stasis, relieve pain with Qi-regulating herbs.

　　2. Medicines: Modified Xuefu Zhuyu Decoction, 15g of Taoren, 15g of Honghua, 15g of Danggui, 20g of Shengdi, 15g of Chishao, 10g of Chuanxiong, 10g of Chaihu, 15g of Zhike, 10g of Gancao, 15g of Chuanshanjie, 15g of Dilong. If there is significant abdominal distension, add 15g of Chuanlianzi, 10g of Yuanhu, 10g of Houpo; if there is cold pain in the abdomen, aversion to cold, add 15g of Xiaomuxiang, 15g of Guanqi, 15g of Wu Yao, 10g of Paojiang.

　　Second. Western Treatment Methods

　　Surgical Treatment:

　　1. To relieve adnexal torsion, if gross observation shows that blood supply is still available and tissue damage can be restored, simply untwist to restore the original blood supply. This situation generally applies to early diagnosis or partial torsion, cases without venous thrombosis, and the adnexal tissue can basically be restored after untwisting. To prevent recurrence, the ovarian ligaments can be shortened or (and) the ovarian pole can be sutured and fixed to the pelvic lateral wall or the posterior uterine wall, especially for children and young adults who need to preserve fertility. However, this conservative treatment has the risk of embolism, and the advantages and disadvantages should be carefully weighed during surgery.

　　1. Salpingo-oophorectomy should be performed if there is thrombosis or necrosis in the fallopian tube or ovarian vessels to avoid pulmonary embolism. Ovarian vessels should be clamped at the proximal end of the torsion site, and close attention should be paid to the position of the ureter. Torsion of the adnexa often leads to tension of the adjacent peritoneum, presenting as a tent-like bulge, bringing the ureter close to the pedicle of the torsion. Clamping and ligating can easily cause injury. Therefore, it is best to incise the peritoneum of the pelvic funnel ligament, free the ovarian arteries and veins, and then clamp, cut, and ligate.

　　2. Laparoscopic surgery has been reported to untwist under laparoscopic vision, observe for 10 minutes, restore blood supply to ischemic areas, and provide conservative treatment for those with minimal tissue damage. Some patients, in addition to untwisting, also underwent ovarian fixation surgery. Mage (1989) reported 35 cases, of which 77% underwent untwisting only, and follow-up showed that ovarian function recovered in all cases, without any complications, but 1 case recurred 12 months later.