Jennifer Dietrich

271 statements · 2 topics · summaries given as host listed separately

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One little trick to look for clear lesions that almost look like little blebs that are kind of pulling away from the peritoneum is to fill up the pelvis with a little bit of crystalloid fluid and then take your camera and dive under, and you can see things a little bit closer.

quote · Ovarian Torsion

we want to try to avoid an oophorectomy and a salpingo oophorectomy at all times. And so we really try to save it, you know, once you untwist it, give it time, and You'd be surprised how many, many purple, black and blue ovaries recover over time.

quote · Ovarian Torsion

the complete absence of blood flow is the most concerning and is more reliable. The presence of blood flow is actually less reliable, believe it or not, on an ultrasound.

quote · Single Ventricle / HLHS

The funny thing about a hemorrhagic cyst is that sometimes if you don't get all of the cyst wall, it continues to bleed.

quote · Single Ventricle / HLHS

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Jennifer's statements about Ovarian Torsion 108 statements

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Ovarian Torsion with Dr. Jennifer Dietrich

Statement In all reproductive age females presenting with lower abdominal pain, a pregnancy test should be checked regardless of sexual activity history. Open

Statement Ultrasound provides adequate penetration for ovarian evaluation in both low and high BMI females when the patient has a full bladder. Open

Statement Significant asymmetry between ovaries on ultrasound, particularly enlargement on the symptomatic side, raises concern for adnexal torsion. Open

Statement Complete absence of blood flow on ultrasound is the most concerning and reliable finding for torsion; presence of blood flow is less reliable and does not rule out torsion. Open

Quotation the complete absence of blood flow is the most concerning and is more reliable. The presence of blood flow is actually less reliable, believe it or not, on an ultrasound. Open

Quotation if a patient has that clinical picture, you know, is in significant pain, has, you know, a good story for an acute onset of pain that's really kind of been progressively worsening and certainly perhaps with nausea or vomiting, fever, those types of things, in addition to finding abnormalities on the side she's experiencing pain on the ultrasound, we're going to be much, much more worried about a torsion, whether or not they report that there's presence of blood flow Open

Statement Blood flow may be present in torsion because only the tube is torsed (ovary still perfused) or because the torsion is intermittent or loose rather than complete. Open

Statement Intermittent torsion can occur, and if the diagnosis is uncertain, observation with repeat ultrasound may help if the patient declares herself with worsening pain. Open

Statement Peripheralization of follicles to the ovarian periphery suggests vascular congestion from torsion, as the edematous center pushes follicles outward. Open

Statement Lesions 5-6 cm or larger increase the risk of torsion in the setting of symptoms by making the adnexa heavy enough to twist. Open

Quotation in prepubertal girls, sometimes it was a normal ovary that was tors and the the most. Often the reason that those little girls actually went to surgery for a gynecologic reason was because we found a torsd ovary in a prepubertal child. Open

Statement In prepubertal girls, normal ovaries can torse, and torsion is the most common reason for gynecologic surgery in this age group. Open

Statement There is no absolute size cutoff for torsion risk; in a prepubertal child with a normally 1-1.5 cm ovary, even a 2-3 cm cyst can cause torsion. Open

Quotation you know, their ovaries are very tiny and so may only be 1 centimeter, 1.5 cm in total size, but normal ovaries can twist. Open

Statement Complex ultrasound features (partly cystic, partly solid), hypervascular flow on Doppler within a lesion, and elevated tumor markers raise concern for malignancy. Open

Statement CT is useful to distinguish an adnexal lesion from an abscess or appendiceal pathology; MRI is useful to distinguish torsion from müllerian anomalies with hematosalpinx. Open

Statement The tumor marker panel for pediatric ovarian lesions includes alpha-fetoprotein, quantitative beta-HCG, lactate dehydrogenase, and CA-125. Open

Quotation the one thing you just can't predict sometimes unfortunately is who has a loose torsion and has a bit more time versus who has a really tight torsion and is really going to have ischemia develop quickly. Open

Statement It is impossible to predict preoperatively whether a torsion is loose (more time available) or tight (rapid ischemia), so suspected torsion should be addressed as soon as the diagnosis is made. Open

Statement If clinical suspicion for torsion is high, it is a clinical diagnosis and surgery should proceed regardless of ultrasound findings; if uncertain, observation with potential repeat imaging is acceptable but the patient should not be sent home. Open

Quotation if really your clinical suspicion is high, it is a clinical diagnosis, and you should act on that. Open

Quotation I mean, don't hesitate to observe a patient if it's, if it's unclear. I mean, I wouldn't just send them home Open

Statement A classic torsion presentation includes acute onset pain after vigorous physical activity (gymnastics, bouncing on a boat), persistent pain unresponsive to over-the-counter measures, nausea and vomiting, and an enlarged ovary on the symptomatic side. Open

Statement Hemorrhagic ovarian cysts are more likely in menstruating females; menstrual history (regularity, timing of last cycle) helps determine risk for hemorrhagic or corpus luteum cysts. Open

Statement In hemorrhagic cysts, Doppler shows no flow within the cyst itself but flow peripheral to the cyst, which can help differentiate from torsion. Open

Statement Surgical management of torsion includes detorsion and removal of any causative lesion (ovarian or peritubal cyst) to eliminate the weight that caused torsion. Open

Quotation we are going to detour the ovary, obviously, and you know if we see a lesion such as a peritubal cyst or an ovarian cyst, we are going to take it out. Open

Statement Oophorectomy and salpingo-oophorectomy should be avoided; the goal is ovarian salvage even when the ovary appears purple, black, and blue, as many recover over time. Open

Quotation we want to try to avoid an oophorectomy and a salpingo oophorectomy at all times. And so we really try to save it, you know, once you untwist it, give it time, and You'd be surprised how many, many purple, black and blue ovaries recover over time. Open

Statement For ovarian cysts, cystectomy (complete excision of cyst wall) is preferred over drainage alone; peritubal cysts will recur if not completely excised. Open

Statement For peritubal cysts, open the mesosalpinx beneath the splayed fallopian tube, expose the cyst wall, and shell it out. Open

Statement For hemorrhagic ovarian cysts, if the cyst wall is not completely removed, the cyst may continue to bleed. Open

Quotation I would still try to save it. And so, you know, detourse it, give it some time, try to address an ovarian or peritubal lesion if you see one, and you know, we attempt to leave it. And so really unless that ovary and or tube are kind of just literally as you're trying to untwist the adnexa, it's just kind of falling apart. We, we try to salvage it. Open

Statement Even necrotic-appearing ovaries should be salvaged unless the tissue is literally falling apart during detorsion; follow-up studies show return of ovarian function and follicles within months. Open

Quotation remarkably, even at our own institution we've done some follow-up studies on just a small subset of patients who've had an ovarian torsion, and you know, people have return of ovarian function, those that were already pubertal, and evidence of follicles. And so sometimes it just takes a few months for things to kind of get back to normalcy. Open

Statement Whether to remove a necrotic fallopian tube depends on whether it is involved in the torsion and completely devitalized; this is a judgment call at the time of surgery. Open

Statement Ovarian bivalving involves making an incision into the ovarian cortex after detorsion to release compartment syndrome-like pressure and improve blood supply to the periphery. Open

Statement Bivalving is indicated when the ovary remains edematous after detorsion, when there is no lesion to remove but the ovary is bulky and at risk for re-torsion, or when debulking is needed after cystectomy. Open

Statement Energy devices such as harmonic scalpel or monopolar hook can be used for ovarian bivalving and debulking. Open

Statement Oophoropexy is considered in cases of recurrent torsion, when a patient has only one ovary, or when the ovary remains at high risk for re-torsion after addressing the primary pathology. Open

Statement Oophoropexy may change future fertility potential by altering ovarian position, but preserving the ovary is better than losing it, and IVF remains an option. Open

Statement Absorbable suture can be used for oophoropexy to hold the adnexa still for 4-6 weeks while inflammation resolves, minimizing near-term re-torsion risk; permanent suture is used for long-term fixation. Open

Statement Clipping the utero-ovarian ligament does not reliably prevent torsion because the adnexa can still twist on either the utero-ovarian ligament or the infundibulopelvic ligament. Open

Statement Oophoropexy techniques include shortening the utero-ovarian ligament (by suturing or clipping it in an accordioned fashion), pexing to the pelvic sidewall (away from ureters), or pexing to the posterior uterus. Open

Statement For tubo-ovarian abscess, antibiotics should be started and the abscess should not be disturbed surgically unless the patient is unstable, to avoid seeding other pelvic structures. Open

Statement Ectopic pregnancy can present similarly to torsion with acute pain and an adnexal mass; surgery is indicated for ruptured or unstable ectopic regardless of pregnancy status. Open

Statement Transvaginal ultrasound is more sensitive than transabdominal for detecting early pregnancy, but many children's hospitals do not perform or have access to transvaginal probes. Open

Statement For tubal ectopic pregnancy, perform salpingostomy (longitudinal incision), remove the ectopic pregnancy, ensure hemostasis, and do not suture the tube closed; pelvic structures heal well without suturing and suturing may cause stricture. Open

Statement Endometriosis in adolescents presents with early lesions that are clear or red rather than the classic blue-black lesions seen in adults with advanced disease. Open

Statement To visualize clear endometriosis lesions, fill the pelvis with crystalloid fluid and dive the camera under to see bleb-like lesions pulling away from the peritoneum, particularly in the cul-de-sac. Open

Statement Endometriosis lesions can be excised with cold scissors (especially near ureter or bowel) or ablated depending on location. Open

Statement After laparoscopic management of torsion, patients can be discharged the same day if they meet milestones, with activity restriction for 4-6 weeks to allow incision healing and avoid hernia formation. Open

Statement Oral contraceptives can prevent recurrence if the torsion was caused by a functional cyst, but they do not prevent recurrence from dermoid cysts or peritubal cysts. Open

Statement Surveillance ultrasound is performed at 3 months postoperatively (to allow inflammation to resolve), then at 3-6 months if the ovary is still recovering, then annually. Open

Ovarian Torsion with Dr. Jennifer Dietrich

Statement In all reproductive age females presenting with lower abdominal pain, a pregnancy test should be checked regardless of sexual history. Open

Statement Ultrasound provides real-time and still pictures with better penetration capabilities regardless of patient BMI, as long as the female has a full bladder. Open

Statement Significant asymmetry between ovaries on ultrasound, particularly enlargement on the side of pain, raises concern for adnexal torsion. Open

Quotation The complete absence of blood flow is the most concerning and is more reliable. The presence of blood flow is actually less reliable, believe it or not, on an ultrasound. Open

Statement Complete absence of blood flow on ultrasound is the most concerning and more reliable finding; presence of blood flow is actually less reliable in diagnosing torsion. Open

Statement Blood flow may be present in ovarian torsion because it could be just a torsed tube, in which case flow to the ovary would still be visible. Open

Statement Intermittent torsion can occur, and if diagnosis is difficult, observation with repeat ultrasound may help if the patient's condition declares itself. Open

Statement When the ovary is edematous with compromised blood supply, follicles become peripheralized to the ovary's periphery due to vascular congestion in the middle. Open

Statement In the literature, cysts around 5 or 6 centimeters in size increase concern for torsion risk in the setting of symptoms, as they make the ovary and tube heavy enough to twist. Open

Statement In prepubertal girls, normal ovaries can torse, and torsion is the most common reason these children undergo surgery for a gynecologic indication. Open

Statement There is no specific size cutoff for torsion risk; diagnosis is based on clinical presentation. Prepubertal ovaries are very small (1-1.5 cm), but normal ovaries can still twist. Open

Statement Complex features on ultrasound (partly cystic, partly solid) with hypervascular flow within the lesion and elevated tumor markers raise concern for malignancy. Open

Statement CT is beneficial to distinguish an adnexal lesion from an abscess or appendiceal pathology when infection is a concern. Open

Statement MRI is useful to distinguish torsion from Müllerian anomalies with outflow tract obstruction, where a hematosalpinx may mimic torsion on ultrasound. Open

Statement Pelvic exams in adolescents are typically delayed until later teenage years or until the first Pap smear at age 21, unless specific concerns arise. Open

Statement Tumor markers sent for complex adnexal masses include alpha-fetoprotein, serum beta-HCG quantitative, lactate dehydrogenase, and CA-125. Open

Statement At Texas Children's Hospital, three out of four tumor markers return within an hour to hour and a half, allowing results before OR posting. Open

Statement It is unpredictable whether a patient has a loose torsion with more time or a tight torsion with rapid ischemia development, so diagnosis should be addressed as soon as possible. Open

Statement Ovarian torsion is a clinical diagnosis; if clinical suspicion is high, surgery should proceed regardless of ultrasound findings including blood flow. Open

Quotation If really your clinical suspicion is high, it is a clinical diagnosis, and you should act on that. Open

Statement If the diagnosis is uncertain, observation for a few hours is reasonable to see if a patient with intermittent torsion declares herself, but the patient should not be sent home. Open

Quotation I mean, don't hesitate to observe a patient if it's, if it's unclear. I mean, I wouldn't just send them home. Open

Statement A classic torsion presentation includes acute onset abdominal pain after physical activity (gymnastics, cartwheels), persistent pain unresponsive to over-the-counter measures, nausea and vomiting, and ultrasound showing ovarian asymmetry on the painful side. Open

Statement Hemorrhagic ovarian cysts are more likely in females who are already menstruating, and menstrual history (regularity, timing of last cycle) helps determine risk for hemorrhagic or corpus luteum cysts. Open

Statement Doppler can help differentiate hemorrhagic cysts from torsion: within a hemorrhagic cyst there is no flow, but peripheral to the cyst there is flow. Open

Statement At surgery for torsion, the ovary is detorsed and any lesion (peritubal or ovarian cyst) is removed, as the lesion's weight made the adnexa prone to twisting. Open

Quotation We really try to save it, you know, once you untwist it, give it time. Open

Quotation You'd be surprised how many, many purple, black and blue ovaries recover over time. Open

Statement Oophorectomy and salpingo-oophorectomy should be avoided at all times; even purple, black and blue ovaries can recover over time after detorsion. Open

Statement For non-ischemic torsion, cystectomy is performed rather than simple drainage unless the cyst is clearly functional. Open

Statement Peritubal cysts will recur if not completely excised; the technique involves opening the mesosalpinx beneath the fallopian tube and shelling out the cyst wall. Open

Statement For expanding hemorrhagic cysts, the cyst should be removed and bleeding areas coagulated; if the cyst wall is not completely removed, the cyst may continue to bleed. Open

Quotation The funny thing about a hemorrhagic cyst is that sometimes if you don't get all of the cyst wall, it continues to bleed. Open

Statement Even necrotic-appearing ovaries should be salvaged unless the tissue is literally falling apart during detorsion; ovarian function and follicles can return after a few months. Open

Statement Follow-up studies at Texas Children's Hospital show return of ovarian function and evidence of follicles in patients who had torsed ovaries preserved. Open

Statement Whether to remove the fallopian tube along with a necrotic ovary depends on whether the tube is involved in the torsion and completely devitalized or salvageable. Open

Statement Bivalving may be needed when the ovary remains edematous after detorsion, to debulk the ovary and reduce re-torsion risk, especially when there is no lesion to remove. Open

Statement Energy devices such as harmonic scalpel or monopolar hook can be used for ovarian bivalving and debulking procedures. Open

Statement Oophoropexy is considered when a child has lost one ovary and presents with torsion of the remaining ovary, or in cases of recurrent torsion. Open

Statement Oophoropexy may change future fertility potential, but preserving the ovary is better than losing it; in vitro technologies remain an option for egg retrieval. Open

Statement Absorbable suture material can be used for oophoropexy to hold the adnexa still for 4-6 weeks while inflammation resolves, minimizing near-term re-torsion risk. Open

Statement Clipping the utero-ovarian ligament does not always prevent torsion because torsion can occur on either the utero-ovarian ligament or the infundibulopelvic ligament. Open

Statement Oophoropexy techniques include shortening the utero-ovarian ligament (by suturing it closer together), fixation to the pelvic sidewall (avoiding ureters), or fixation to the back of the uterus. Open

Statement For tubal-ovarian abscess, antibiotics should be started and the abscess should not be disturbed unless the patient is crashing, to avoid seeding other pelvic structures. Open

Statement Ectopic pregnancy can present similarly to torsion with acute pain and an adnexal mass, and may not be visible on transabdominal ultrasound if beta-HCG levels are below the threshold for visualization. Open

Statement For tubal ectopic pregnancy, a salpingostomy is made, the ectopic pregnancy is removed, hemostasis is ensured, and tissue is submitted for pathology; the tube is not sutured closed. Open

Statement Pelvic structures heal well without suturing; suturing can cause more scar tissue and stricture formation than leaving small incisions to heal on their own. Open

Statement Endometriosis in young adolescents presents with atypical lesions (clear or red) rather than the classic blue or black lesions seen in adults with advanced disease. Open

Quotation One little trick to look for clear lesions that almost look like little blebs that are kind of pulling away from the peritoneum is to fill up the pelvis with a little bit of crystalloid fluid and then take your camera and dive under, and you can see things a little bit closer. Open

Statement To identify clear endometriosis lesions, fill the pelvis with crystalloid fluid and examine the cul-de-sac closely with the camera underwater to see blebs pulling away from the peritoneum. Open

Statement Endometriosis lesions can be excised with cold scissors when near the ureter or bowel, or ablated in other locations. Open

Statement Patients can go home within a few hours after laparoscopic surgery if they meet postoperative milestones, with activity limited for 4-6 weeks to allow incision healing and avoid hernia formation. Open

Statement Oral contraceptive pills can prevent recurrence if the torsion was caused by a functional cyst, but will not help with dermoid cysts or peritubal cysts. Open

Statement Surveillance ultrasound is obtained at 3 months post-surgery (allowing time for inflammation to resolve), then at 3-6 months if the ovary is still recovering, then annually. Open

Jennifer's statements about Single Ventricle / HLHS 163 statements

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