Combining point-of-care ultrasound with physical examination in a pediatric emergency department of ovarian torsion: A case report

Abstract

BACKGROUND

Point-of-care ultrasound (POCUS) is the use of portable ultrasound devices by trained healthcare professionals to diagnose and monitor medical conditions directly at the patient's bedside, such as in emergency settings. We described a case where POCUS use, in Pediatric Emergency Department, allowed an early diagnosis and timely management in the surgical department, with a favorable outcome for child. Therefore we write this case because it is desirable to popularize ultrasound as the fifth pillar of clinical examination especially in Emergency Department

CASE SUMMARY

A 13-year-old girl with acute gastrointestinal symptoms, such as vomit and abdominal and lumbar pains. Upon physical examination, the patient had localized abdominal pain in the left lower quadrant. Ultrasonography performed at the bedside revealed an enlarged left ovary with an irregular structure containing a 3 cm cyst. These findings raised suspicion of ovarian torsion. The child transferred to Gynecology Surgery Unit, where she was taken emergently to the operating room

CONCLUSION

It is desirable to spread POCUS in emergency settings where it allows a significant saving of time in patient management.

Key Words: Point-of-care ultrasound; Fifth pillar; Ovarian torsion; Black-bluish ovary; Emergency Department; Case report

Core Tip: The use of point-of-care ultrasound in the Emergency Department enable early diagnosis and timely intervention, in a 13-year-old girl with ovarian torsion, presented with acute gastrointestinal symptoms, leading to a favorable outcome. This case supports the integration of bedside ultrasound as a fifth pillar of clinical examination, especially in the Emergency Department.

INTRODUCTION

Point-of-care ultrasound (POCUS) is the use of portable ultrasound devices by trained healthcare professionals to diagnose and monitor medical conditions directly at a patient's bedside, such as in an emergency setting. POCUS can be used in various settings like hospitals, Emergency Departments, and ambulances. It provides real-time imaging, it helps healthcare professionals to make informed clinical decisions, and it guides treatment interventions quickly and effectively[1]. In critically ill patients, combining POCUS with physical examination is highly beneficial. It enables clinicians to perform quick, real-time assessments that are tailored to a patient's urgent clinical needs, integrating both visual and tactile information for more accurate diagnosis and treatment. In the Emergency Department, POCUS is a game-changer, enabling clinicians to make quicker decisions in urgent situations by providing immediate, real-time imaging at the bedside. In pediatric care, POCUS is especially valuable because it is non invasive, well tolerated by children, and avoids exposure to ionizing radiation, making it a safe and effective diagnostic tool. Pediatricians in Emergency Departments can use POCUS for various conditions, including abdominal pain, to detect appendicitis, intestinal obstruction, and intussusception, as well as respiratory issues like pneumonia or foreign body aspiration. Its use in pediatrics allows for more accurate and efficient diagnoses, especially in children who may be harder to assess due to their smaller body size, rapidly changing clinical conditions, and challenges with traditional imaging techniques[2]. In this case, the use of POCUS in the Pediatric Emergency Department enabled early diagnosis and timely management in the surgical department, resulting in a positive outcome for the child. This case underscores the importance of promoting ultrasound as the 'fifth pillar' of clinical examination, even in pediatric emergency settings, to enhance the care of pediatric patients

CASE PRESENTATION

Chief complaints

This case presents a 13-year-old girl, with normal height and weight, caucasian race.

History of present illness

She came to our Pediatric Emergency Department with acute gastrointestinal symptoms, such as vomiting and abdominal and lumbar pains.

History of past illness

She had a history of menarche at 10 years, with regular, painless menstrual cycles, which were ongoing at the time of presentation.

Personal and family history

Past personal and family medical history was unremarkable. She reported no drug allergies and she was up to date with her vaccinations.

Physical examination

Upon physical examination, the patient had localized abdominal pain in the left lower quadrant, but her vital signs were normal.

Laboratory examinations

Laboratory (routine blood tests, routine urine tests and urinary sediment examination) results were normal.

Imaging examinations

Ultrasonography performed at the bedside revealed anechoic fluid collection in the pelvic cavity, which appeared on both sides, along with an enlarged left ovary with an irregular structure containing a 3-cm cyst (Figure 1). These findings raised the suspicion of ovarian torsion, a gynecological emergency, due to the presence of an ovarian cyst and anechoic fluid.

Figure 1 Bedside point-of-care ultrasound in emerging department revealed an enlarged left ovary with a 3 cm cyst, raising the suspicion of ovarian torsion. A: Detail of a 3 cm cyst in the left ovary; B: The ovary is enlarged with irregular morphology, causing displacement of the bladder.

MULTIDISCIPLINARY EXPERT CONSULTATION

Given the concern of ovarian torsion, the patient was transferred to the Gynecology Surgery Unit for further evaluation.

FINAL DIAGNOSIS

A Gynecology expert confirmed ovarian torsion diagnosis.

TREATMENT

She underwent emergency surgery, where the affected ovary was detorsed and part of it was removed.

OUTCOME AND FOLLOW-UP

The postoperative recovery was smooth, and the patient had no complications. She had no complications at the 3-month clinical and ultrasound follow-up.

DISCUSSION

Ovarian torsion is a gynecological emergency, primarily affecting patients under 20 years of age, and accounts for 2%–7% of Acute Abdomens. Although it can occur at any age in the pediatric population, ovarian torsion has two peaks of incidence: Up to 52% of cases occur between ages 9–14, and up to 16% of cases occur in the first year of life[3]. In fact, these age groups have a higher incidence of cysts of various types (dermoid cysts, hemorrhagic or follicular ovarian cysts, paratubular or paraovarian cysts, cystadenomas, and polycystic ovaries), which can act as a focal point, predisposing to ovarian torsion, especially when they are larger than 3 cm[4].

The transabdominal ultrasound, associated with the study of blood flow using color Doppler, is the method of choice for diagnosis. However, to date, there are no clinical or imaging criteria sufficient to confirm the preoperative diagnosis of ovarian torsion[5]. In fact, the presence of blood flow on color Doppler does not completely exclude the possibility of ovarian torsion, and a definitive diagnosis can only be made through surgical exploration[6]. Surgical treatment options include ovarian detorsion, ovarian detorsion with oophoropexy (surgical fixation of the ovary to the lateral pelvic wall to prevent future recurrence), and surgical removal (oophorectomy)[7]. In the past, the management of a twisted ovary with an ischemic and hemorrhagic appearance was traditionally ovariectomy. However, several studies have suggested that ovarian preservation in the pediatric age group is preferable despite its appearance, due to the well-established reparative ability of the ovary itself[8]. Although the exact duration of the vascular interruption required to cause irreversible damage to the ovary is still unknown, and the ovary's double blood supply (uterine-ovarian vessels and infundibulo-pelvic vessels) makes it resistant to vascular injuries, the vitality of the ovary decreases over time, from the onset of pain to surgical detorsion. Therefore, the black or bluish macroscopic appearance of the ovary (black-bluish ovary) and presumed ovarian necrosis at the time of detorsion are not reliable indicators of the organ's vitality, and are not correlated or correlatable with the current or future ability of the ovary to develop follicles[9]. However, an early diagnosis, compared to the onset of symptoms, increases the likelihood of saving the adnexa. Timely intervention is key, as early surgical treatment can prevent more complicated procedures such as total resection of the ovary[9,10]. In this case, the attending physician's use of POCUS helped to establish an early diagnosis, which facilitated prompt intervention and a favorable outcome for the patient. In this diagnostic challenge, the strength of POCUS is its ability to provide real-time, immediate visual confirmation of suspected conditions, complementing physical examinations by offering and enabling quick decision-making.

The integration of POCUS with clinical examinations offers a more comprehensive and efficient diagnostic approach, enabling physicians to make timely decisions without the delays associated with traditional imaging methods. In this case, ovarian torsion was suspected due to the combination of abdominal pain, ultrasound findings, and the presence of a cyst. Early diagnosis and surgical intervention were crucial for preserving the patient’s ovarian function and preventing further complications. To our knowledge, there are few cases that have emphasized the utility of POCUS in pediatric emergency settings, highlighting the uniqueness of the described case. It is desirable to encourage learning periods for the POCUS technique among pediatric emergency physicians.

CONCLUSION

Our case illustrates that, in emergency settings, POCUS can save valuable time in patient management, leading to better outcomes. Therefore, it is essential to promote ultrasound as the "fifth pillar" of clinical examination at the bedside. Expanding POCUS use not only improves pediatric training but also has the potential to enhance patient outcomes, particularly in emergency settings.

ACKNOWLEDGEMENTS

We thank our colleagues from the Gynecology Unit of “Cannizzaro” hospitals for their contribution. Who endorse the data and conclusions.