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DIAGNOSIS:

Right ovarian torsion

A markedly enlarged right ovary is seen with edematous afollicular central stroma showing patchy heterogeneous enhancement with multiple small follicles within, associated with a twisted vascular pedicle along its posterolaterally aspect.

Also seen was ipsilaterally deviation of the uterus with mild non-hemorrhagic free fluid in the pelvis and in bilateral lower paracolic gutters. The left ovary also appears bulky with presence of multiple (<20) peripherally arranged non-hemorrhagic follicles raising a possibility of polycystic ovarian disease. 

Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. Ovarian torsion is usually associated with a cyst or tumor, which is typically benign; the most common is mature cystic teratoma. In our case, no mass is identified, but the left ovary shows features suggestive of polycystic ovarian disease (PCOD), which is also a known cause of ovarian torsion.
 
Ultrasonography (US) is the primary imaging modality for evaluation of ovarian torsion. US features of ovarian torsion include a unilateral enlarged ovary, uniform peripheral cystic structures, a coexistent mass within the affected ovary, free pelvic fluid, lack of arterial or venous flow, and a twisted vascular pedicle. The presence of flow at color Doppler imaging does not allow exclusion of torsion but instead suggests that the ovary may be viable, especially if flow is present centrally. Absence of flow in the twisted vascular pedicle may indicate that the ovary is not viable. The role of computed tomography (CT) and magnetic resonance imaging (MRI) has expanded, and it is increasingly used in evaluation of abdominal pain. Common features of ovarian torsion seen on cross sectional imaging include an enlarged ovary, uterine deviation to the twisted side, smooth wall thickening of the twisted adnexal cystic mass, fallopian tube thickening, peripheral cystic structures, and ascites. 

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