The ultrasound showed a right kidney with a little bit of hydronefrosis, mild at most, but the “money shot” was in the pelvis ..
A large cystic mass with anechoic to hyperechogenic content, some concrement-like structures were also seen within.
Right kidney Left kidney
The patient was sent to gynaecology where a transvaginal ultrasound was done …. with similar findings.
On basis of the findings of the ultrasound(s) she was brought to the OR. Where the gynaecologist found the large cyst (9 – 6 – 5 cm) which had facilitated a torsion of the right ovary. Luckily the ovary could be spared.
The pathology report showed : Cyst with skin, bone, cartilage and braintissue.. conclusion : mature teratoma
Final diagnosis : Large mature teratoma with torsion of the right ovary (and little bit of hydronefrosis of the right kidney)
A few pearls can be taken from this case in my humble opion:
-Be sceptic of other people’s diagnosis when a patient is handed over to your care, don’t let it narrow your frame of thinking
-Emergency ultrasound can guide your management in the right direction within seconds.Without it you might lose valuable time (and in this case an ovary)
-Always scan the pelvis/bladder after doing renal ultrasound, don’t be satisfied with hydronefrosis, check if you can identify the cause downstream. (also always take a look at the aorta by the way, AAA /iliacal aneurysm can also be a cause of hydronefrosis and mimic renal colic)
- Torsion of the ovary can be a tricky diagnosis, pelvic exam not always helpful.
Love to hear your comments on this case …. Check EMdutch in a month or so for the next emergency ultrasound case !!