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Paper 3
Published in Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw, The Final FRCR, 2020
Amanda Rabone, Benedict Thomson, Nicky Dineen, Vincent Helyar, Aidan Shaw
Ultrasound and fluoroscopy can be helpful in assessing for midgut volvulus. Ultrasound findings include the ‘whirlpool’ sign caused by a twisting of the mesenteric vessels. The superior mesenteric vein usually lies to the right of the superior mesenteric artery; in malrotation it lies to the left. The retro-mesenteric D3 part of the duodenum may not be visible between the aorta and superior mesenteric vessels.
Benign Adnexal Masses and Adnexal Torsion
Published in Juan Luis Alcázar, María Ángela Pascual, Stefano Guerriero, Ultrasound of Pelvic Pain in the Non-Pregnant Female, 2019
The twisted pedicle (the “whirlpool sign”) can be detected using color Doppler (Figure 1.18) or grayscale ultrasound (Figure 1.19).47–49 This finding is considered almost pathognomonic for adnexal torsion. When observed, the adnexal torsion was confirmed at laparoscopy in 90%–100% of patients.
Abdominal Pain in Pregnancy
Published in Tony Hollingworth, Differential Diagnosis in Obstetrics and Gynaecology: An A-Z, 2015
Ramesh Kuppusamy, Dilip Visvanathan
Torsion of the vascular pedicle leads to acute severe ischaemia, and the patient will present with acute abdominal pain, nausea, and vomiting. Presentation is usually in the second trimester of pregnancy or in the puerperium, when there is space in the pelvis to undergo torsion. Clinical examination may reveal a patient who lies still in bed and may have tenderness in the lower abdomen. Signs of rebound tenderness, guarding, and rigidity are uncommon. Ultrasonography is important in making the diagnosis. The most consistent feature of a twisted ovary is an enlargement of the ovary to a mean diameter that is greater than 4 cm. The ovarian follicles usually are found in the periphery of the ovary; this is described as the ‘string of pearls’ sign. A coexistent mass (usually a dermoid cyst) may be found in the ovary. Free fluid in the pouch of Douglas is almost always present. More recently ultrasonologists have concentrated on studying the vascular pedicle itself. Grayscale ultrasound can demonstrate the twisted ovarian pedicle. Doppler studies show a target-like appearance that has been described as the ‘whirlpool’ sign. The presence of this sign indicates that the ovary is still viable. Absence of blood flow to the ovary would indicate that the ovary is not viable. These additional features help in pre-operative counselling – where every attempt should be made to conserve the ovary by untwisting it at surgery. Early diagnosis is therefore imperative if oophorectomy is to be avoided.
Internal herniation through the foramen of Winslow: a case report
Published in Acta Chirurgica Belgica, 2020
Yanina Jeanne Leona Jansen, Koenraad Nieboer, Ellie Senesael, Kobe Van Bael, Mathias Allaeys
Most internal herniations occur after abdominal surgery. This condition is very well known after a gastric bypass with a classic whirlpool sign on CT. However internal herniation can also occur in patients through natural orifices, especially in patients with a mobile ascending colon or caecum. Like all other herniations, this can lead to bowel strangulation which is associated with a high mortality (between 36 and 49%; [1]). The four most common orifices are the lesser sac via the foramen of Winslow, the paraduodenal fossa, the retrocaecal fossa and the intersigmoid fossa. A herniation through the foramen of Winslow is a rare event (1–8% of internal herniations; Forbes and Stephen 2006, [2]) and appears to be more frequent in men (ratio 2.5:1) with a peak incidence between 20 and 60 years of age [1]. Most frequently a small bowel loop (63%) becomes lodged followed by the caecum and ascending colon (30%) and the transverse colon (7%). But even a diverticulum of Meckel, a caecal bascule or the gallbladder can herniate. The cause of the herniation is unknown. Leung et al. postulated that a herniation through the foramen of Winslow is rare because the orifice is kept close by the intraperitoneal pressure. However, an abnormal anatomy such as an enlarged foramen, a defect in the gastroduodenal ligament or a mobile caecum could lead to a herniation [1].
Adnexal torsion in symptomatic women: a single-centre retrospective study of diagnosis and management
Published in Journal of Obstetrics and Gynaecology, 2019
Padmasree Resapu, Sirisha Rao Gundabattula, Vijaya Bharathi Bayyarapu, Manjula Pochiraju, Kameswari Surampudi, Shashikala Dasari
This was a retrospective study of women with abdominal pain who either underwent surgery for suspected adnexal torsion or were found to have torsion intraoperatively. Women with the ultrasound features of torsion but which was not confirmed by surgery and the asymptomatic patients with incidental operative finding of torsion during surgery performed for other reasons were excluded. Preoperatively, adnexal torsion was diagnosed based on clinical suspicion with or without sonographic concordance. Classically, this presents as acute-onset abdominal pain, nausea and vomiting with or without an adnexal mass. The sonographic features suggestive of torsion include: enlarged, oedematous and displaced ovary, ovarian mass (sometimes tender), multiple small peripheral follicles, hyperechoic rings around the antral follicles (follicular rings), decreased or no blood supply to the ovary and whirlpool sign in the ovarian vessels (Sibal 2012; Laufer 2015).