The double bladder sign: Challenges in early sonographic diagnosis of ovarian torsion.

Ovarian torsion is an emergency whereby challenges in diagnosis may lead to delayed management. The morbidity associated with delayed diagnosis can be severe and includes loss of ovarian function. We present a case of a 24-year-old female who presented to the hospital with left lower quadrant abdominal pain with unremarkable physical examination. A transabdominal and transvaginal ultrasound were acquired and demonstrated a mildly enlarged left ovary and fallopian tube without other significant findings. However due to worsening pain and up trending inflammatory markers, diagnostic laparoscopy was performed and demonstrated a 12cm ovarian cyst, a necrotic left adnexal mass and a torsed left tubo-ovarian pedicle. These findings were not appreciated on the initial Doppler ultrasound acquired but retrospective analysis demonstrated a double bladder sign. Our case report aims to aid sonographers and physicians to promptly diagnose ovarian torsion through the "double bladder sign" and other salient ultrasonographic and clinical features.

Torsion of the gallbladder: a rare but important differential to consider when treating acute cholecystitis non-operatively.

A 79-year-old woman presented with postprandial epigastric pain. She had normal vital signs, inflammatory markers and liver function tests. Ultrasound and CT of the abdomen demonstrated features consistent with acute cholecystitis. Her medical comorbidities and extensive abdominal surgical history prompted the decision to treat non-operatively. Despite optimal medical management, worsening abdominal pain and uptrending inflammatory markers developed. She underwent an emergency laparoscopy which revealed a necrotic gallbladder secondary to an anticlockwise complete gallbladder torsion; a rare condition associated with significant morbidity and mortality if managed non-operatively. Laparoscopic cholecystectomy was achieved without complication and the patient had an uneventful recovery. Preoperative diagnosis of torsion of the gallbladder is difficult. However, there are certain patient demographics and imaging characteristics that can help surgeons differentiate it from acute cholecystitis; a condition which can be safely managed non-operatively in selected patients. The differentiating features are elaborated on in this case report.