HEMATOSALPINX WITH MULTIPLE TORSIONS OF TUBE IN 11 YR MORBIDLY OBESE GIRL.

Objective: Isolated Fallopian tube torsion (IFTT) with hematosalpinx is a very rare condition in adolescents and a difficult diagnosis. A high index of suspicion is needed for timely diagnosis in young girls to save the tube.

 

Case report: A 11yr old female , morbidly obese BMI of 48,presented  with complaints of severe lower abdominal pain  and  unable to pass urine since 6 hours.History of occasional lower abdominal pain since 1 week.She attained menarche 1 year back.On examination vitals were stable , per abdomen , abdominal wall was thick and  fatty with  tenderness over the midline .Sonography revealed a right adnexal cyst of 8*7 cm with few thickened septa suggestive of a large right paraovarian cyst. MRI pelvis showed 10*7*8 cm midline cystic lesion indicating either a mesenteric cyst  or a paraovarian cyst. In view of persisting abdominal pain, patient was taken up for laparoscopy.

 

Intraoperative findings revealed a normal sized uterus and normal ovaries on both sides. Left fallopian tube was healthy.Right fallopian tube was dark,unhealthy and distended around 6 *6 cm with blood in the infundibulum, fimbrial end could not be differentiated and the ampullary part hypercoiled around  5 - 6 turns with a pseudo knot  .On untwisting, dense bowel adhesions to the tube noted,  and adhesiolysis done. Post detorsion, the colour of the tube did not improve and the tube was fragile and necrotic. After counselling ,and with informed consent of the parents, proceeded with laparoscopic right salpingectomy. Post operatively, the patient recovered uneventfully and was discharged after 2 days.On follow up after 1 week patient was in good health. 

 

Discussion: IFTT is a very uncommon condition with prevalence of 1 in 1.5 million  and is even less frequent in the paediatric population. (1)The exact cause is not known but several predisposing factors are described. The intrinsic factors include excessive length of the tube ,hypermobility, spasm of the tube , hydrosalpinx, and hematosalpinx.The extrinsic factors are ovarian cyst ,paraovarian cyst , PID , and adhesions.In our case hematosalpinx was noted ,may be due to retrograde menstruation and dense bowel adhesion to the tube, a sequelae of PID. Though PID is very unusual in sexually inactive girls it cannot be excluded. IFTT should also be contemplated in girls who actively participate in sports with sudden movements (2). It  has a very non-specific presentation and with no cardinal signs on imaging poses a  challenge to the clinician.Laparoscopy is the gold standard for diagnosis and early diagnosis is the key  to conserve the tube or else laparoscopic salpingectomy becomes the modality of treatment .

 

Conclusion: Increasing the awareness amongst clinicians about IFTT and its timely diagnosis will aid in salvaging  the fallopian tube which will positively impact the  fertility potential of young girls.

 

References:1. Ferrera PC, Kass LE, Verdile VP. Torsion of the fallopian tube. Am J Emerg Med 1995; 13:312-314.

2.Bertozzi M., Noviello C., Molinaro F., et al. Isolated fallopian tube torsion in pediatric age: an Italian multicenter retrospective study. Journal of Pediatric Surgery . 2020;55(4):711–714.