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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