Uterine leiomyoma torsion: A rare cause of acute abdominal pain

Abstract

INTRODUCTION: Leiomyoma torsion is an incredibly rare entity. Diagnosis is frequently intraoperative due to poor correlation between clinical symptoms and radiological findings. We report a case of a twisted uterine leimyoma diagnosed intraoperatively. CASE PRESENTATION: Our patient was 46 years old, nulliparous woman, presented to the emergency department with three days of acute pelvic pain. On physical examination, a firm and tender pelvic mass was palpable, extending below the umbilicus, suggestive of uterine origin. Laboratory investigations revealed an inflammatory response. Ultrasound identified a large abdomino-pelvic mass adherent to the right side of the uterus, with no detectable blood flow on Doppler examination. Given the diagnostic uncertainty, exploratory laparoscopy was performed. The diagnosis of a pedunculated Leiomyoma torsion with acute appendicitis was confirmed. Initially we performed a fibroid detorsion then a myomectomy and appendectomy were performed. CLINICAL DISCUSSION: The torsion of the vascular pedicle of a subserous leiomyoma can lead to ischemic gangrene and peritonitis, which can cause mortality. The risk factors that contribute to the fibroid torsion include the size, the stalk of the pedunculated myoma that must be thin and long in order for it to undergo rotation and torsion. There are no specific clinical signs or imaging modalities that reliably indicate the diagnosis. A diagnostic laparoscopy is most often indicated in case of diagnostic doubt. Surgery may consist in myomectomy or hysterectomy. CONCLUSION: It is important to consider the possibility of torsed leiomyoma in the differential diagnosis in any woman presenting with an intra-abdominal and pelvic mass with acute abdomen.