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Ultrasound InACUTE PELVIC PAIN
Wei-Lien Yee - Senior sonographerDr Monica Pahuja – Consultant Radiologist
Subspecialty Head Gynecology/Breast
What we will cover
• Gynaecologicalo Ovarian Torsiono PIDo Ruptured ovarian cyst/haemorrhagic cysto OHSSo Ectopic IUCD
• Non- Gynaecologicalo Acute appendicitiso Diverticulitiso Urolithiasis
Ovarian Torsion
• Two main reasons
o Hypermobility of the ovary < 50% *
o Adnexal mass (50-80%)* This is the lead point
• Rotation of ovary on vascular pedicle
• Clinical
o Lower abdominal pain (+/- oscillating)
o Adnexal tenderness
o +/- Raised white cell count
• Masses > 5cm at most risk
*https://radiopaedia.org Glick, Y et al
Take home message
Ovarian Torsion: Sonographic Appearances
• Well Understoodo Unilateral enlarged ovary
o Heterogeneous • Oedema and hemorrhage
o Peripherally arranged follicles
o Free fluido Focal tenderness
• Reviewo Absent or reduced vascularityo Whirlpool sign of a twisted pedicleo Ovarian mass – lead point
• Cystic, solid or both• Usually benign
Echogenic central stroma
Peripheral displacement of
follicles.
Overall increased volume of ovary
Ovarian Torsion: Colour & Doppler
• Variable appearance• Venous flow
o Decreased or absent o Due to collapse of the compliant venous wall
• Arterial flow o Reduced, absent or reversed in diastoleo Arterial flow preserved
• Dual blood supply from Ovarian Artery / Uterine Artery
• Intermittent torsion o Can have normal flow
Take home message
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Ovarian Torsion: Whirlpool Sign
Snail shell appearance of a twisted vascular pedicle (arrows).
Colour whirlpool. Take home message
Very Helpful
Whirlpool sign- B-mode
23 yr old
RIF pain
Normal inflammatory markers? ovarian cyst
Whirlpool sign- Colour38yo
RIF pain for 1/7 with severe pain overnight
Bloods unremarkable
US 2/52 prior for surveillance of a known Rt unilocular ovarian cyst
Whirlpool sign35yo
Sudden onset of 10/10 LIF pain
Coming and going
–ve bHCG ? torsion
Pelvic Inflammatory Disease
• Infection of the female urogenital tract• Source
o ascending infection of vagina or urethra
• Spectrum of infectiono Cervicitiso Endometritiso Salpingitis/pyosalpinxo Tubo-ovarian abscesso Pyometra
• Right upper quadrant pain from peri-hepatitis in Fitz-Hugh-Curtis syndrome is possible
CLINICAL DIAGNOSIS Centre for Disease Control and Prevention (CDC).
12 Minimum Criteria
(At least 1 needed for diagnosis)
CLINICAL Elevated WCC Elevated ESR
Vaginal dischargeTemperature
DEFINITIVE CRITERIA Histopathological findings of endometritis
Imaging findings of pyosalpinx
TOADoppler confirmation of hypervascularity of pelvic
structures
Cervical motion tendernessUterine tenderness Adnexal tenderness
Criteria for PID
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Pelvic Inflammatory Disease: Ultrasound
• Varying appearances – may be normal or non-specific Ultrasound Q. 2004 Dec;20(4):171-9
• Role of Ultrasound
o Differentiate from other causes of infection
• Appendicitis, UTI
o Characterize pelvic collections/masses I.Thomassin-NaggaraaE.DaraibM.Bazota
Take home message
Pelvic Inflammatory Disease: Endometritis
• Inflammation of the endometrium
• Obstetric causes and non-obstetric causeso STI o Invasive gynecological procedure
• Sonographic Appearances o Thickening and/or irregularity of the endometriumo Increased vascularityo Gas – echogenic foci with posterior shadowingo +/- intracavity fluid
https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/uog.107
https://sonoworld.com/CaseDetails/Endometritis.aspx?ModuleCategoryId=572
Pelvic Inflammatory Disease: Salpingitis
• Inflammation of the tube
• Sonographic Appearances o Vary
o Bilateral adnexal masses• 2-3cm in diameter• Solid /thick-walled unilocular /multi-loculated cystic
• Echogenic fluid within• Increased vascularity
o Free fluid Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study
G. Romosan1,*, C. Bjartling
1, L. Skoog
2, and L. Valentin
Pelvic Inflammatory Disease: Pyosalpinx
• Infection of the tube with obstruction
• Sonographic Appearances o Complex adnexal masso Unilateral or bilateral
o Thick walled, serpiginous o Increased peripheral vascularity, echogenic fluid
o Cog-wheel sign or incomplete internal septaeo Surrounding inflammatory changes
• Pelvic free fluid• Surrounding echogenic inflammatory fat• +/- Ovarian enlargement, endometritis
o TenderBajo Arenas, JM & Perez-Medina, Tirso & Luque, Juan Mario. (2005
Pyosalpinx36yo presented OP
Pelvic pain
Irregular menses
46yo Pelvic pain
Raised WCC
Pyosalpinx
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Pelvic Inflammatory Disease: Tubo-Ovarian Abscess
• Inflammatory mass o Both fallopian tube and ovary
• Risk factors:o PIDo IUCDo DM or immunocompromiseo Multiple sexual partnerso Previous surgery
• Presentation:o Combination of pelvic pain, fever, raised inflammatory markers,
+/- vaginal discharge
Pelvic Inflammatory Disease: Tubo-Ovarian Abscess
• Ultrasound: Primary Signso Unilateral or bilateral complex adnexal masso Fallopian tube / ovary not seen discretelyo Mass
• Multiloculated,
• Solid/cystic
• Ill-defined borders,
• Internal septa
• Fluid-debris level
• Thick walls with florid vascularity
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/tog.12447 https://pubs.rsna.org/doi/full/10.1148/rg.312105090
Pelvic Inflammatory Disease: Tubo-Ovarian Abscess
• Ultrasound: Secondary Signso Surrounding inflammatory change
• Pelvic free fluid• Surrounding echogenic inflammatory fat
o Uterus may be enlarged with ill-defined marginso +/- Internal gas
37 y.o 2 x Sudden onset lower abdominal pain.Dr advises the patient had severe pain on Saturday and was
reviewed at another hospitalSent home on analgesia.
Pelvic Inflammatory Disease: Tubo-Ovarian Abscess
• CTo Pelvic malignancyo Complex diverticular abscesso Appendicael abscesso Pelvic endometriosiso Hydro-pyosalpinxo Ectopic pregnancyo Ovarian torsion
Case courtesy of Dr Henry Knipe, <ahref="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/26157">rID: 26157</a>
Pelvic Inflammatory Disease: Tubo-Ovarian Abscess TOA42yo
P/W acute pelvic pain, fevers
Hx of chronic PID
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Pelvic Inflammatory Disease: Tubo-Ovarian Abscess
Velcani A, Conklin
• Mimicso Endometriosis
o Malignancy
Haemorrhagic/ Ruptured Ovarian Cyst
• Acute pelvic pain: Common
• Premenopausal age group
• Role of Ultrasoundo Simple or haemorrhagico ? collapsed
• Pain may also be due to acute haemorrhage into a large cyst
• DDx. ruptured ectopic pregnancy (correlate with bHCG)
Haemorrhagic Cyst / Ruptured Ovarian Cyst
• Ultrasoundo Thin wallo Retracted clot
• mimics nodule (no vascularity)
• Posterior enhancement• No internal blood flow
• Free fluid in pelvic if simple cyst- rupture• Haemoperitoneum
Hemorrhagic and ruptured cystFishnet or reticular pattern Retracting clot appearance Fluid debris levels Ruptured cyst
• Mimics
• Endometriosis
• Tumors
Haemorrhagic/ Ruptured Ovarian Cyst
Resolves in 6-8 weeks
No resolution
Ovarian Hyperstimulation Syndrome (OHSS)
• Usually o Complication of ovarian stimulation treatment o IVF
• Rarelyo Spontaneous in pregnancy
• Clinical syndrome o Marked Ovarian Enlargement o Weight gaino Asciteso Pleural effusionso Intravascular volume depletion with haemoconcentrationo Oliguria
• May effect up to 5% of patients undergoing IVF
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Ovarian Hyperstimulation Syndrome (OHSS)
• Ultrasoundo Bilateral symmetrical enlargement of ovaries (>12cm)o Multiple cystic lesions
• Enlarged follicles or corpus luteum cysts • Classic spoke-wheel appearance
• +/- ascites• +/- pleural effusion• +/- pericardial effusion• Assess for torsion, cyst hemorrhage or rupture
.
Ovarian Hyperstimulation Syndrome (OHSS)23yo
1st cycle of IVF
Abdominal distention
Abnormal LFTS
Decreased urine output
.
Ovarian Hyperstimulation Syndrome (OHSS)23yo
1st cycle of IVF
Abdominal distention
Abnormal LFTS
Decreased urine output
Ectopic IUCD
RIGHT ARM INTOMYOMETRIUM
Non- Gynaecological
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Appendicitis
• Clinicalo Usually a disease of young ( peak incidence 20-30 years)o Fevero Localized pain and tenderness- pelvic paino Flank paino Nausea vomitingo Loss of appetite
• Sites:o Behind Caecum – ascending 65%. Transverse 2%o Inferior to caecum 31%o Anterior to the ileum 1%
Appendicitis
• Well Understood
• What’s Currento 6-8mm – Discriminatory zoneo Report locationo Large phlegmon - Difficult
7mm appendixEchogenic mucosaMild tender
Normal appendix Abnormal appendix Appendicitis
12yo 5/7 RIF pain and fever
Diverticulitis• Complication of colonic diverticulosis and diverticular disease• Acute diverticulitis is life-threatening
o Uncomplicated diverticulosis is asymptomatic
• Symptoms o Unremitting pain/tenderness in the left iliac fossao Right sided diverticulitis is rare
• Clinicalo Palpable ill-defined mass
• CT is imaging modality of choice• Often found on US when ruling out other causes• Focus on point of maximal tenderness Take home message
Normal layers of the bowel wall Diverticulitis
o Focal outpouching of mucosal layer o Associated bowel wall thickening
(>4mm)o Echogenic, non-compressible fato Hyperemia on colour Dopplero Normal wall signature is lost
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Diverticulitis
38yo femalePara-umbilical and RIF pain ? Ruptured ovarian cyst
Urolithiasis
• Mean age group broad 30-60 yrs
• Senstivity of ultrasound compared to CTKUB is 24%
o 75% of calculi <3 mm not visualized
• Findingso Echogenic foci
o Acoustic shadowing
o Twinkle artefact on colour Doppler
o Colour - comet-tail artefacto Hydroureter
o Hydronephrosis
• https://radiopaedia.org/articles/urolithiasis?lang=us. Bell etal
• https://appliedradiology.com/
Conclusion
• Variety of cause
• Think gynaecological/ non-gynaecologicalo Difficult for referrers
• Dependent on o Clinical historyo Age groupo US findings
Thankyou
References• Ultrasound for diagnosing acute salpingitis: a prospective observational diagnostic study G. Romosan1, C. Bjartling1, L. Skoog2, and L. Valentin
• Bajo Arenas, JM & Perez-Medina, Tirso & Luque, Juan Mario. (2005). Sonography of pelvic infection. The Ultrasound Review of Obstetrics & Gynecology. 5. 81-90. 10.1080/14722240500104864
• Fallopian Tube Disease in the Nonpregnant Patient MaryamRezvani , Akram M. Shaaban Published Online:Mar 7 2011
• Velcani A, Conklin P, Specht N. Sonographic features of tubo-ovarian abscess mimicking an endometrioma and review of cystic adnexal masses. J Radiol Case Rep. 2010;4(2):9-17.
• Zivi E, Simon A, Laufer N. Ovarian hyperstimulation syndrome: definition, incidence, and classification. SeminReprodMed2010;28(6):441–447.
• Sienas, Laura & Miller, Trevor & Melo, Juliana & Hedriana, Herman. (2018). Hyperreactio luteinalis in a monochorionic twin pregnancy complicated by preeclampsia: A case report. Case Reports in Women's Health. 19. e00073. 10.1016/j.crwh.2018.e00073.
• Chang et al Radiographics Sep 2008
• https://radiopaedia.org Glick, Y et al
• Vandermeer, Fauzia Q and Jade Janette Wong-You-Cheong. “Imaging of acute pelvic pain.” Clinical obstetrics and gynecology 52 1 (2009): 2-20
• Teixeira, ArildoCorrêa, Urban, Linei A. B. D., Zapparoli, Mauricio, Pereira, Caroline, Millani, Thaís Cristina Cleto, & Passos, Ana Paula. (2008). Degenerating cystic uterine fibroid mimics an ovarian cyst in a pregnant patient: a case report. Radiologia Brasileira, 41(4), 277-279
• Ultrasound Imaging of Bowel Pathology: Technique and Keys to Diagnosis in the Acute Abdomen
• American Journal of Roentgenology 2011 197:6, W1067-W1075