Shah N*, Paranjpe SH**, Jindal N***.
(*Consulting Gynecologist/Obstetrician, Hon. Endosopic Surgeon Wadia Hospital & Railway Hospital, Byculla, **Director Velankar Hospital & Paranjpe Maternity Home, Chembur, ***Consultant Anesthesiologist, Mumbai, India.)
Isolated Fallopian tube torsion is a rare gynecological cause of chronic or acute lower abdominal pain. There are no specific investigations like imaging, or blood workup. Very rarely, a diagnosis is made before the operation. In this case, we present a case of a 46 year old female undergoing a hysterectomy. She had an incidental finding of a twisted fallopian tube with 7 turns and a blood supply from the bowel.
Fallopian tube torsion without ovarian torsion is a rare identity. Its incidence in the reproductive age group is 1 in 1.5 million. Presentation is usually similar to that of an ovarian torsion, but pain may be chronic dull aching and vague as compared to ovarian torsion.
A 46 year old multiparus woman with previous 2 normal deliveries came to our OPD with chronic dull aching lower abdominal pain since 1 year. She had symptoms of irregular menses with menorrhagia. She had no other symptoms like fever, nausea, vomiting or vaginal discharge. On physical examination, there was no focal tenderness. On pelvic examination, right ovarian tenderness was noted, but no cervical motion tenderness could be elicited. All routine blood and urine tests were within normal limits.
Ultrasonography showed a bulky uterus with 2 small intramural fibroids. Both ovaries were normal and no free fluid was seen in the pelvis. She was posted for a total Laparoscopic Hysterectomy for abnormal uterine bleeding. During laparoscopy, the uterus was bulky but normal in appearance. Both ovaries were normal. Right sided tube was dilated with mild hydrosalpinx with isolated 7 twists of the fallopian tube. Another unique feature that was found, was that the tubal end had a parasitic blood supply from the bowel. The adhesion was coagulated and cut and then the untwisting was done 7 times to finally completely untwist the fallopian tube. Bilateral salpingectomy was performed after the hysterectomy. Diagnosis of torsion and hydrosalpinx was established on histopathology.
Figure 3. Twist, 2nd.
Figure 4. Twist, 3rd.
The exact mechanism of isolated fallopian tube torsion is not well understood. Various documented causative factors include, prior surgery such as tubal ligation, hematosalpinx, hydrosalpinx, or other tubal neoplasms. There are also various physiological factors which can cause torsion which include hyper motility of the fallopian tube, or tubal spasm or increased peristalsis. Other congenital pathologies have also been mentioned which include long tubal size, excessive spiral nature of the tube, incomplete mesosalpinx, and large cysts of morgagni. Extrinsic factors for tubal torsion may include ovarian or para ovarian cyst, tubal adhesions, uterine enlargement due to any tumor or pregnancy. Besides these, the Sellheim theory states that tubal torsion can occur due to sudden body position changes, or trauma or venous congestion in the mesosalpingeal area. An undiagnosed torsion may undergo alternate states of torsion and detorsion which may finally lead to chronic nature of the torsion.
Clinical presentation of an isolated fallopian tube torsion is quite nonspecific. Pain may be specific but is usually vague dull aching generalized lower abdominal pain. Nausea vomiting may accompany. Pelvic examination does not reveal much as hydrosalpinx is not always palpable. Ultrasonography may pick up hydrosalpinx but can be easily missed as in this case. Laboratory findings are also nonspecific. Leukocytosis may be present if necrosis has occurred. CRP may be raised. Many reports have also suggested that torsion of fallopian tube is more likely to occur on the right side. This is because of the partial immobilization of the left tube because of the sigmoid and mesocolon of the left side. Also it is more likely for patients to get operated for right lower abdominal pain due to suspicion of appendicitis.
Complications of tubal torsion include local necrosis leading to gangrenous transformation and super infection. This did not occur in our case even after 7 twists as it had obtained a parasitic blood supply from the bowel.
Thus, although a rare entity, differential for tubal torsion must be kept in mind if ultrasonography shows both normal ovaries and a hydrosalpinx. Delay in diagnosis may lead to increased morbidity.
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Shah N, Paranjpe SH, Jindal N. Seven (7) Twists Of Fallopian Tube With Parasitic Blood Supply. JPGO 2019. Volume 6 No.7. Available from: https://www.jpgo.org/2019/07/seven-7-twists-of-fallopian-tube-with.html