 I'm going to talk about acute pelvic pain. So patients who present with pelvic pain in the emergency department, and we're going to do it all bit differently. We're going to do case-based because it may be a little bit more fun. This is a 40-year-old woman with low abdominal pain. She had this very large ovarian mass that looks like, for all the world, like a cystic turtoma, where there's a shadow of mass with shadowing, there's this dermoid mesh right there. But look at the positions above the uterus, and the patient has pain. So what we're going to do is try to find a twist. And if you look at the edge of the mass here, you see this knot right there. It's relatively vascular in this case. And so this is the twisted pedicle of a tors dermoid. And again, this is what... So we see the dermoid here, which is discolored. It's purple because it's in a course. But you're also looking in between the uterus and the mass of this, like, the twisted pedicle. So what are the ultrasound findings in ovarian torsion? Well, you're going to see an enlarged heterogeneous ovary. You may or may not see a mass, because oftentimes this patient will have a mass which adds at a lead point, a foam for the torsion. If there's no mass, you're going to see peripherally displaced follicles. Sometimes they have a necrogenic wind because there is edema around the follicles. Think about torsion. It's a position of the ovaries unusual, either in the culver sac or flipped above the uterus. And again, in these cases, you look for and you have to search for it for the twisted pedicle, which will appear as a target of warped appearance. Oftentimes the patient will have exquisite focal tenderness over the torsed ovary. And we'll talk about the dopper signs a little bit later, but unlike the testicle, the dopper signs in ovarian torsion can be variable. And the gray scale is really the most important finding. So let me show you a few cases. This is a 50-year-old with pelvic pain, so that she's a little old. Usually ovarian torsion has been in slightly younger patients, but she had this mass, solid mass in the culver sac. And if you look at the, paid attention to prior lecture, it's an hyperequic mass with shadowing, so it looks like a fibroma, but this position in the culver sac, really somewhat unusual. And here's again, the twisted pedicle. She also had a CT and NMR. And again, there's a little bit of a fluid, so that's always why you might use fluid, that this could be torsion. And so what she had was a torsed ovarian fibroma, which infected. This is a 29-year-old woman who has multiple emergency room visits for pain. And if you look at the ultrasound, so there's a lesion in the culver sac, and this is, as all the classic findings of ovarian torsion, with the peripheral follicles, with ecogenic borders, but this was an outside hospital. And they were confused by the fact that there was flow in the ovaries. So they didn't think about the diagnosis of torsion because of the flow. And if you look at the CT, she does have signs in CT that also should make you think about torsion. You can see that the ovaries in the culver sac is not enhancing normally. There is acides. There is tilting of the uterus towards the side that torsion. There's another sign on CT, and here is a twisted pedicle. And perhaps you can see that twisted pedicle a little bit better on the coronal reconstructions. So this is to say that the Doppler findings in ovarian torsion are variable. Oftentimes, there is no flow, of course, but sometimes you may have a little bit of flow, and sometimes in this only case I've seen, this is an old case, but this patient had recurrent pelvic pain and ovary that just looks like ovarian torsion, but she had increased flow. And so I told the gynecologist it still looks like ovarian torsion. I don't understand why she has increased flow. So she went in, and indeed the ovary was torsed, but she figured maybe it was torsion, detorsion, and there was some reactive hyperenia. Now the other thing, the flip side is, so the grayscale in ovarian torsion is really the most important finding, in my opinion. Provided the patient has the appropriate symptoms of pain, nausea, sometimes vomiting. But if you see a normal ovary with no flow, usually that's technical, because in ovarian torsion if you think about the mechanism, you have twisting of the pedicle. So you have first obstruction of venous outflow, and so the ovary enlarges and becomes edematous, and ultimately there is enough twisting, you have also an absence of ovarian inflow, and so you have necrosis as well. So you have a combination of dima, hemorrhage, and necrosis, and therefore the ovary usually is enlarged and usually is abnormal in aqua texture. So again, just to recap, the CT findings in ovarian torsion are large, hypoenhancing ovary more than six centimeters. Usually think about it, the ovary is in an unusual position, either in the cul-de-sac or above the uterus. If it's a cystic mass that is acting as a fulcrum, you may have asymmetric wall thickening, you may have lack of septal enhancement, you may have deviation of the uterus towards the sign that the ovary that is twisted. And again, as I showed you, you see the twisted pedicle on CT and you can have complex focalocytes. Again, this is another case where the sonographer, they had ordered a venous ultrasound, but the sonographer asked the patient, why does it hurt, and it hurt over the ovary. So this was a patient who was pregnant with twins. And so if you look at the ovary here, it's a little bit large, and the follicles are a little peripheral, and her other ovary was not as large and the patient was vocally tender there. So then we went in to try to solve, find out what was going on. And again, if you look for it, you'll see the twisted pedicle right here between the uterus here, so it's the placenta and the ovary, which is clearly not. The other thing is in patients who are very thin, it's helpful to use a linear transducer, when you see the equatextor, when you see the multiplicity of follicles in the ovary much better with a linear transducer. Here's the twisted pedicle in color. The other important thing here is that the ovary was enlarged and the patient had pain, but it wasn't as abnormal an equatextor the cases I showed you first. So we told them, maybe this ovary still vibe, right? So they went in the OR very, very soon after the ultrasound. And you can see here that the ovary is, there is twist, but the, first of all, the twist wasn't as tight, and the ovary is still viable. It's not purple. So they de-twisted the ovaries, de-twisted, and the patient went on to deliver her twins and was okay, and they were able to salvage the ovary. Now this patient is 25 years old. It was her third episode of left-sided pain in the past six months. She had no nevexal mass, and she came in with sudden onset of left flank pain and left inguinal pain in one episode of vomiting. So she had a CT scan first, and here's her CT. So you see this cystic mass in the cul-de-sac with some fat stranding. And again, you see this mass right there, but it seems like you see both ovaries on the coronal, as well as the axial CT. So she had an ultrasound or an ultrasound. Here's the mass in the cul-de-sac with this weird kind of debris floating around, no flow, really, to speak of. This is just artifact at the edge, but then when we saw, you know, it looked like torsion, but when we look at the ovaries, though, the right and the left ovaries were both completely normal in size, and they could see flow. So what's going on? This is likely to be isolated and nevexal torsion. And this is what happened at surgery. She had a six-ton-meter fluid-filled cyst at the distal end of the tube. The tube up here, dusty and purple, it was twisted 360 degrees. It was untwisted, but ultimately, they ended up doing the left sub-projectomy with a large pair of tubal cysts that were removed. And it's likely that this pair of tubal cyst predisposed the Pelopon tube to torsion. So isolated tubal torsion is really uncommon. It's often misdiagnosed. Predisposing factor is hydro or hematose outpanks. The presence of pair tubal or pair ovarian cysts or adhesions. And on ultrasound, this is what you're going to see. The ovaries are going to be normal, but there is a cystic mass adjacent to the ovary and the patient was usually severe pain with symptoms mimicking ovarian torsion. Sometimes you'll see a thickened fallopian tube, and if you really think about the diagnosis, try to find the whirlpool sign of the twisted fallopian tube.