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Obstetrics & Gynecology 2006;108:100-102
© 2006 by The American College of Obstetricians and Gynecologists
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ORIGINAL RESEARCH

Adnexal Torsion Involving Hydatids of Morgagni

A Rare Cause of Acute Abdominal Pain in Adolescents

Moty Pansky, MD1, Noam Smorgick, MD, MSc1, Gad Lotan, MD2, Arie Herman, MD1, David Schneider, MD1 and Reuvit Halperin, MD, PhD1

From the Department of 1 Obstetrics and Gynecology and the Department of 2Pediatric Surgery, Assaf Harofe Medical Center, Zerifin, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.


   ABSTRACT
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ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: Hydatids of Morgagni are common embryonal remnants of the müllerian duct and among the infrequent causes of adnexal torsion. The purpose of this study was to investigate the occurrence of adnexal torsion involving hydatids of Morgagni, as well as its possible mechanisms.

METHODS: A database search was conducted for cases of adnexal torsion treated in our institution from January 2002 to July 2005. These cases were analyzed, focusing on a subgroup of adolescents with adnexal torsion involving the hydatids of Morgagni.

RESULTS: There were 76 patients with adnexal torsion. The rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15–0.51) in the adolescent subgroup (10–19 years old), compared with 0% (0 of 61 cases, 95% CI 0–0.048) in the adult subgroup. The difference between the hydatid torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001–0.532). The four patients with hydatid torsion (postmenarchal girls, aged 13–18 years) were managed with laparoscopic adnexal detorsion and cystectomy of the affected hydatid of Morgagni. At surgery, we noted three different mechanisms of hydatid torsion: torsion of the adnexa together with torsion of the hydatid of Morgagni, torsion of the hydatid of Morgagni with intact adnexa (n = 2), and entanglement of the hydatid's pedicle around the distal fallopian tube. The hydatids of Morgagni were observed on the preoperative transabdominal ultrasonogram in only one patient and appeared as a simple cyst.

CONCLUSION: Adnexal torsion involving the hydatids of Morgagni appears to be more common in adolescents than previously thought.

LEVEL OF EVIDENCE: III

Hydatids of Morgagni are benign, pedunculated, cystic structures arising from the fimbriated end of the fallopian tubes. These serous-type, fluid-filled cysts are müllerian duct remnants and usually measure 1–2 cm.1 Most hydatids of Morgagni are incidental findings at pelvic laparotomy/laparoscopy and have no clinical significance. Rarely, torsion of a hydatid of Morgagni around its pedicle may produce acute abdominal pain. This clinical presentation was previously described in anecdotal case reports.2 We investigated adnexal torsion involving hydatids of Morgagni and now describe the clinical presentation, the possible torsion mechanisms, and the correlation of preoperative ultrasonography with operative findings.


   PATIENTS AND METHODS
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ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
We retrospectively reviewed the medical records of 76 women with surgically confirmed adnexal torsion who underwent surgery in our institution from January 2002 to July 2005. Cases were identified by search of a computerized database. Sixty-one patients were adults (aged 20–57 years), whereas 15 patients were adolescents (aged 10–19 years). The classification of patients into the adolescent and adult subgroups was based on the World Health Organization's definition of an adolescent as a person between 10 and 19 years of age. Their clinical presentations, preoperative ultrasound scans, operative reports, and pathologic diagnoses were analyzed.

The proportions of torsion cases involving hydatids of Morgagni in adolescents and adults were compared with the two-tailed Fisher exact test. A P < .05 was considered statistically significant. This study was approved by the institutional review board of our institution.


   RESULTS
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ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
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Adnexal torsion involving the hydatids of Morgagni constituted 5.3% (4 of 76 cases) of all surgically confirmed torsion cases during the study period. The four patients with hydatid of Morgagni torsion were white, postmenarchal virgins, aged 13–18 years. Thus, the rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15–0.51) in the adolescent subgroup (10–19 years old), compared with 0% (0 of 61 cases, 95% CI 0–0.048) in the adult subgroup. The difference between the torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001–0.532). Three of the patients were ordinarily healthy, whereas the fourth had had nephrolithiasis. All four patients presented with localized lower abdominal pain and nausea without fever. The abdominal pain was described as intermittent in three cases and as constant in the fourth. The duration of symptoms before hospital admission was 12–96 hours. The physical examination revealed abdominal tenderness in all cases. In addition, the per rectal examination detected a round, tender, and mobile pelvic mass in three of the patients. The results of laboratory tests (including complete blood count, electrolytes, amylase, and renal studies) were within normal limits; none of the patients had leukocytosis.

Because the four patients were relatively young virgins, only a transabdominal ultrasound scan was performed (instead of a transvaginal scan). In three of the cases, the ipsilateral adnexa was of normal size (measuring about 3 cm), and no cystic lesions were observed. In the fourth patient, two small simple ovarian cysts were detected by ultrasonography, and the adnexa was moderately enlarged to a diameter of 7.5 cm.

All four patients underwent diagnostic laparoscopy between 5–70 hours after the initial admission. The delay in carrying out surgery in one case was due to the patient's intermittent and milder symptoms. At surgery, three different mechanisms of torsion were noted. Only the hydatid of Morgagni was twisted around its pedicle in two patients, whereas the pedicle of a hydatid of Morgagni was twisted around its pedicle including the distal end of the fallopian tube in a third patient. In the fourth patient, the adnexa and the hydatid of Morgagni were both twisted. In the latter patient, it is likely that the twisted hydatid of Morgagni had pulled the adnexa and thereby produced torsion of the adnexa. The hydatid diameters ranged from 0.6 cm to 2 cm. All four patients were treated by laparoscopic detorsion and cystectomy of the hydatid of Morgagni. The postoperative follow-up was uneventful, and the patients were discharged the next day.

We attempted to correlate the preoperative transabdominal ultrasound findings with the operative findings. The hydatid of Morgagni was not noted in the ultrasound examination of three of the patients. In the fourth patient, the two small cysts that were detected by ultrasonography could be correlated with the operative findings of torsion involving the hydatid of Morgagni and the presence of an ipsilateral small functional cyst.


   DISCUSSION
TOP
ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Hydatids of Morgagni are among the most common benign conditions of the fallopian tubes. These müllerian duct remnants are usually asymptomatic and are discovered as incidental findings at laparotomy or laparoscopy. Rarely, however, has the hydatid of Morgagni been implicated in adnexal torsion that presented as acute or subacute low abdominal pain. Wittich et al2 described a 4 x 3 cm hydatid of Morgagni with torsion of the pedicle on the left fallopian tube of a 39-year-old pregnant woman. A different torsion mechanism involving the hydatid of Morgagni was described by Risk et al.3 They presented the case of a 17-year-old virgin with isolated torsion of the fallopian tube, which also had an ipsilateral small hydatid of Morgagni. They hypothesized that the free end of the fallopian tube was rendered heavier by the hydatid of Morgagni and thus more susceptible to rotation. In the current series, we present four adolescents with adnexal torsion involving the hydatid of Morgagni. We observed three different torsion mechanisms: torsion of the hydatid of Morgagni with intact adnexa (similar to the case previously described by Wittich et al2), torsion of the adnexa together with torsion of the hydatid of Morgagni, and torsion and entanglement of the hydatid of Morgagni's pedicle around the distal fallopian tube.

The clinical presentation of our patients was similar to the usual presentation of adnexal torsion, ie, acute localized abdominal pain and nausea. None had symptoms or signs of necrosis (ie, fever and leukocytosis). Possible explanations are that significant necrosis had not yet occurred because of the short duration of torsion before surgical intervention and that any existing necrotic tissue was relatively sparse.

Because of its small size, the hydatid of Morgagni is more frequently recognized by transvaginal than by transabdominal ultrasonography.4 Because of their relatively young age, our patients were scanned only by transabdominal ultrasonography, which indeed failed to recognize the structure in three of the four cases. In the fourth patient, the hydatid of Morgagni was thought to be a small simple ovarian cyst. Nevertheless, the clinical presentation suggested that torsion had taken place and prompted the surgical intervention.

The adolescents in our series were all managed via laparoscopic adnexal-sparing procedures (detorsion and cystectomy) without complications. This emphasizes the need to perform a diagnostic exploratory laparoscopy whenever torsion is suspected in an adolescent.

All four of our patients were postmenarchal adolescents. Because the hydatid of Morgagni is a congenital structure, it is interesting that torsion has reportedly occurred only over a small age range. The embryonic origin of the structure, the paramesonephric duct, may explain this phenomenon. After the onset of puberty, the secretory activity that is initiated in the epithelial lining of the hydatid of Morgagni may cause its dilation and thereby increase the risk of torsion.

In conclusion, we report that the hydatids of Morgagni were involved in 26% of all cases of adnexal torsion in an adolescent subgroup. Adnexal torsion involving the hydatids of Morgagni appears to be more common in this subgroup than previously thought.


   Footnotes
 
Corresponding author: Moty Pansky, MD, Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Zerifin, 70300 Israel; e-mail: mpansky{at}asaf.health.gov.il.

doi:10.1097/01.AOG.0000220548.99152.0f


   REFERENCES
TOP
ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
1. Perlman S, Hertweck P, Fallat ME. Paratubal and tubal abnormalities. Semin Pediatr Surg 2005;14:124–34.[Medline]

2. Wittich AC. Hydatid of Morgagni with torsion diagnosed during cesarean delivery: a case report. J Reprod Med 2002;47:680–2.[Medline]

3. Rizk DE, Lakshminarasimha B, Joshi S. Torsion of the fallopian tube in an adolescent female: a case report. J Pediatr Adolesc Gynecol 2002;15:159–61.[Medline]

4. Schiebler ML, Dotters D, Baudoin L, Keefe B. Sonographic diagnosis of hydatids of Morgagni of the fallopian tube. J Ultrasound Med 1992;11:115–6.[Medline]





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