Routine US of Ovarian Cysts to R/O torsion?

[Aloha Kid]

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Often times in the ER we are diagnosing ovarian cysts by CT scan. It's the common female RLQ pain picture - what do you do first, CT or US? Lets say CT confirms and ovarian cyst as probable reason for patients RLQ pain. How many of you are then getting an US of the cyst after CT to R/O torsion? In a scenario where CT detects an reasonable sized ovarian cyst in a female with abdominal pain, is US always indicated to R/O torsion?

 

[Birdstrike]

Definitely not always. Its a judgement call. Sudden onset, colicky pain, more severe than your usual patient with a simple un-torsed cyst. Pain on pelvic exam worse than on abd exam. Torsion is rare but easy to miss.

 

[HoochIsCrazy]

Often times in the ER we are diagnosing ovarian cysts by CT scan. It's the common female RLQ pain picture - what do you do first, CT or US? Lets say CT confirms and ovarian cyst as probable reason for patients RLQ pain. How many of you are then getting an US of the cyst after CT to R/O torsion? In a scenario where CT detects an reasonable sized ovarian cyst in a female with abdominal pain, is US always indicated to R/O torsion?

The problem is, US is not a great measure for torsion. In the OB/GYN community, they teach that if you have enough clinical suspicion then the patient should go to the OR. At my institution, OB doesn't even bother with US for RO torsion because it is so unreliable. In one study I read recently, 5/26 patients with torsion had totally normal flow. Because torsion can be intermittent, relying on doppler can be problematic depending on your timing. Now I'm not saying you shouldn't use US. It can support your general clinical picture and obviously has very little risk/cost. I am just saying seeing flow on doppler doesn't reliably exclude torsion.

 

[Hamhock]

The problem is, US is not a great measure for torsion. In the OB/GYN community, they teach that if you have enough clinical suspicion then the patient should go to the OR. At my institution, OB doesn't even bother with US for RO torsion because it is so unreliable. In one study I read recently, 5/26 patients with torsion had totally normal flow. Because torsion can be intermittent, relying on doppler can be problematic depending on your timing. Now I'm not saying you shouldn't use US. It can support your general clinical picture and obviously has very little risk/cost. I am just saying seeing flow on doppler doesn't reliably exclude torsion.

Yes, I have seen similar numbers before...ultrasound just ain't great. The only real way to diagnose torsion is in the OR. That is why torsion scares me...I can't really diagnose it with much certainty.

I doubt I will ever work out in the sticks without OB/Gyn consultants (my interests require a tertiary center), but if I was a community EM doc working far from good Gyn access, I think this would be in the top 5 of my most feared diagnoses.

Major trauma? Not really - just resus/stablize as able and prepare transfer...just do the best you can and hope. There is no real question about what to do.

Ovarian torsion? Well, I am not sure. Am I to transfer every young woman with a big cyst (or even without!?!) and severe, colicky LLQ/pelvic pain?

I am a firm believer that clinical suspicion, in modern emergency medicine, is just...well, suspicious.

Ovarian torsion?

🙁HH

 

[Cerberus]

The problem is, US is not a great measure for torsion. In the OB/GYN community, they teach that if you have enough clinical suspicion then the patient should go to the OR. At my institution, OB doesn't even bother with US for RO torsion because it is so unreliable. In one study I read recently, 5/26 patients with torsion had totally normal flow. Because torsion can be intermittent, relying on doppler can be problematic depending on your timing. Now I'm not saying you shouldn't use US. It can support your general clinical picture and obviously has very little risk/cost. I am just saying seeing flow on doppler doesn't reliably exclude torsion.

I don't know what it's like at your institution but at my institution getting a surgeon to go to the OR without some form of imaging modality is about as likely as getting Donald Trump to say he has a bad hair piece.

 

[The White Coat Investor]

I'm not sure I've ever diagnosed ovarian torsion. I guess that means I've probably missed it.

 

[Rendar5]

I'm not sure I've ever diagnosed ovarian torsion. I guess that means I've probably missed it.

I've diagnosed one, but it was a dead ovary at that point so it wasn't hard. Presented 100% identical to a classic appy presentation in a 12 year old girl, except for the fact it it was worsening over 4 days. The u/s looking for an appy picked up a heterogenous mass and the tech asked us to order a limited pelvic u/s. 3 hours later, a necrotic ovary was removed by gyn and the girl felt much better.

 

[EM_Rebuilder]

Just a few weeks ago while moonlighting I saw a patient with RLQ abd pain, colicky, severe at times.

Further questioning, this was her third visit in a week. She had a CT done 2 days prior. It was read as "Appendix enlarged, no inflammatory changes, rec rescan in 24 hours". I re-scanned her, it was a normal scan. Gyn stuff not commented on.

She was still uncomfortable and had an 'attack' while in the ED. I went with my gut and got the US. They have to call someone in as it was late at night; the tech was not too happy to be there.

I was grinning when the tech came out saying "I think it is a torsion"... Rads confirmed it shortly thereafter and she went to Gyn...

I hated to CT that young woman twice in <1 week, but I felt like my hands were tied when the first CT said what it said.

 

[EctopicFetus]

Honestly, why wouldnt you US a woman? By not ordering the test its all risk on your part and no reward.