Test Your Knowledge Katherine KaprothJoslin MD PhD Ravinder Sidhu MBBS Shweta Bhatt MBBS Susan Voci MD Patrick Fultz MD Vikram Dogra MBBS Deborah Rubens MD All authors have disclosed no relevant relationships ID: 916381
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Slide1
US Assessment of Acute Female Pelvic Pain: Test Your Knowledge
Katherine
Kaproth-Joslin
, MD, PhD
Ravinder
Sidhu, MBBS
Shweta Bhatt, MBBS
Susan
Voci
, MD
Patrick Fultz, MD
Vikram
Dogra
, MBBS
Deborah Rubens, MD
All authors have disclosed no relevant relationships.
Address correspondence to
K.K.J., Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, PO Box 648, Rochester, NY 14642 (e-mail:
katherine_kaproth-joslin@urmc.rochester.edu
).
Slide2Introduction
Acute pelvic pain is a common symptom reported by women presenting to emergency departments and physicians’ offices
Its cause may be gynecologic or
nongynecologic
Identification of the cause on the basis of physical symptoms alone often may be difficult
Ultrasonography (US) is the imaging modality of choice when the underlying cause is thought to be gynecologic
US allows a close look at the pelvic anatomy, including blood vessels, and has two major advantages over other standard pelvic imaging modalities:
It minimizes or eliminates the dose of ionizing radiation to which the patient is exposed during imaging
It allows direct correlation of the region of pain with imaging findings
This image-rich case-based presentation reviews
Common gynecologic and
nongynecologic
causes of acute pelvic pain
Benefits and limitations of US for identifying the specific cause of pain
Circumstances in which the use of other imaging modalities is necessary
Slide3Normal Anatomy of the Female Pelvis: Uterus
The uterus consists of two main parts:
Body
, which includes the
Fundus:
uppermost portion, superior to the fallopian tube ostia Main body: largest portionIsthmus: inferior portion directly above the internal cervical os Cervix, which connects the uterine body to the vagina Size and shape depend on patient age and parityThe uterine wall contains three layers: Serosa: external layer Myometrium: central muscular layerEndometrium: inner mucosal layer
(Illustration created by
Nadezhda
Kiriyak
, Department of Imaging Sciences, University of Rochester, Rochester, NY.)
Slide4Normal Anatomy of the Female Pelvis: Fallopian Tube
Positioned along the superior aspect of the broad ligament
Not well visualized at US
Consists of four segments:
Intramural-cornual segment: Short proximal segment in the uterine cornu Isthmus: Narrow segment connecting the intramural and ampullary portionsAmpulla: Long segment that progressively widens distallyInfundibulum: Funnel-like portion ending in fimbriae(Illustration created by Nadezhda Kiriyak, Department of Imaging Sciences, University of Rochester, Rochester, NY.)
Slide5Normal Anatomy of the Female Pelvis: Ovary
Size and location of ovaries depend on age, menstrual status, and parity
Ovarian parenchyma is divided into two parts
Medulla:
where the blood supply enters and exits the ovaryCortex:Contains multiple randomly distributed folliclesMature vesicular ovarian follicles before rupture have an average size of 2.2 cm (Illustration created by Nadezhda Kiriyak, Department of Imaging Sciences, University of Rochester, Rochester, NY.)
Slide6Pelvic US Techniques
Transabdominal
evaluation
Insonation
is performed through the anterior abdominal wall
Transducer frequencies up to 5 MHz may be usedMay be performed with the bladder full to provide an acoustic window for better assessment of the uterus, adnexa, and other pelvic structuresTransvaginal evaluationAn endovaginal transducer is used with a higher frequency (>7.5 MHz)Insonation is performed after the patient empties her bladderGray-scale imaging is used to assess the contour and morphologic features of the uterus forEndometrial or myometrial defects Endometrial thickening, polyps, or masses (which are then assessed with color Doppler imaging)Gray-scale imaging also may be used to assess the stroma, follicles, and overall volume of the ovary for signs of torsion or a mass (which is then assessed with color Doppler imaging)Has limited usefulness for evaluating the fallopian tubes
Slide7Myometrium: homogeneously
hypoechoic
outer layer
Junctional zone (innermost
myometrial
layer, adjacent to endometrium) is less echogenic than remainder of myometriumEndometrium: hyperechoic inner layerAppearance and thickness vary, depending on age, menarcheal status, and phase of the menstrual cycleTotal thickness of both walls from the anterior to the posterior aspect is measured in the true sagittal plane (blue calipers, top image)Mean thickness in premenopausal women is 1.6 cm; in post-menopausal women, 0.5 cm(Long = longitudinal view, Trans = transverse view)
US Appearances: Normal Uterus
Uterus Long
Uterus Trans
Endometrium
Endometrium
Junctional zone
Myometrium
Junctional zone
Myometrium
Slide8US Appearances: Normal Ovary
Hypoechoic
relative to adjacent myometrium, with medulla slightly
hyperechoic
relative to cortex
Developing follicles are anechoic Corpus luteum cysts may have a thick, echogenic vascular ring with a low- resistance waveform
Ovary trans
Doppler US - ovary
Corpus luteum cyst
Corpus luteum cyst
Ovary long
Slide9Case 1
A 34-year-old woman with a history of kidney stones presents to the emergency department with left lower quadrant abdominal pain and flank pain. No stones are seen at computed tomography (CT). Asymmetric enlargement of the left ovary is seen at US. The result of a pregnancy test is negative. What is the diagnosis?
US findings:
Heterogeneous well- circumscribed mass with lacelike internal echoes
Avascularity
of the massTenderness during direct compressionAnswer:Hemorrhagic cyst of the left ovary
Left ovary
Left adnexa
Left adnexa
Slide10Case 1: Hemorrhagic Cyst
Occurs in women of menstrual age
May be asymptomatic and afebrile with a normal white blood cell (WBC) count
May or may not have a history of ovarian cysts
Pathogenesis: Acute hemorrhage into a follicular or corpus luteum cyst
Massive hemoperitoneum may resultCan cause syncope with or without hypotension Signs and symptoms:Abrupt onset of severe pain in the pelvis or lower abdomenIf hemoperitoneum is present, a preg-nancy test is cru-cial to differentiate a ruptured hemor-rhagic cyst from a ruptured ectopic pregnancy.
Cyst
Hemoperitoneum
Rapid change in the imaging appearance of the cyst may be due to clotting
Most hemorrhagic cysts resolve within two menstrual cycles
US findings:
Cystic structure with a well-defined wall;
may have internal fluid-debris or fluid-fluid levels
Retracting clot (no flow)
Thin, smooth, avascular fibrin strands (fishnet- or lace-like pattern) with no flow
Short-interval US follow-up
examina-tions
are recommended for lesions lar-
ger
than 5 cm in diameter or lesions with an unusual appearance.
Fishnet-like pattern
Retracting
clot
Slide11Case 2
A 44-year-old woman presents to the emergency department with exacerbation of asthma, left lower quadrant abdominal pain, nausea, and constipation. What is the diagnosis?
US findings:
Enlarged, globular uterus
Ill-defined endometrium
Myometrial cyst
Uterus transverse
Uterus sagittal
Ill-defined endometrium
Answer:
Adenomyosis
Myometrial
cyst
Slide12Case 2:
Adenomyosis
Occurs in 20%–30% of women, most often multiparous women
.
Pathophysiology:
Endometrial gland migration into the myometrium; process is often diffuse, but may be focalSubendometrial cysts may be presentSigns and symptoms:Chronic pelvic pain Soft, tender, enlarged uterus; menorrhagia; dysmenorrhea; infertilityGray-scale US findings:
Enlarged, globular uterus
Loss of endometrial-
myometrial
junction
Ill-defined echogenic areas in myometrium
Swiss cheese–like appear-
ance
created by
myometrial
cysts 1–5 mm in diameter
Echogenic striations within endometrium and
hypoechoic
striations within myometrium
Color Doppler US findings:
No mass effect on the vessels
Cysts are easily differentiated from blood vessels
US is the imaging method of choice, but if findings are
equivo-cal
or fibroids are present, a mag-
netic
resonance (MR) imaging evaluation is recommended.
Adenomyosis
Slide13Case 3
A 23-year-old woman presents to her gynecologist with a constant, dull abdominal pain ongoing for a week, accompanied by a vaginal odor and brown vaginal discharge. The patient had undergone placement of an intrauterine device (IUD) 4 months earlier. What is the likely diagnosis based on the US and CT findings shown below?
US findings:
Echogenic linear material outside the uterus
CT findings:
Linear metallic structure outside the uterus, indicative of IUD displacement
Answer:
Extrauterine
malposition of IUD
Companion case, same diagnosis
Slide14Case 3: IUD Malposition
Transvaginal
US findings of
normal
IUD position:
Echogenic object within the endometrial cavity; crossed bars in the fundus
IUD may be echogenic (
eg
,
Mirena
; Bayer Healthcare Pharmaceuticals), producing a linear “bright” region with or without an acoustic shadow
If the IUD is not seen at US, evaluation with another imaging method is needed. Pelvic radiography may be helpful for locating the IUD.
Transverse
Pathophysiology:
Migration of a contraceptive device from the endometrial cavity into the bowel, ovary, or bladder
May be asymptomatic
Signs and symptoms:
Pelvic pain (generalized or localized)
Cervical motion tenderness
Irregular bleeding, pain during menses
Infection
Ectopic pregnancy
Sagittal
Gray-scale US images show normal IUD position.
Coronal
Slide15Case 4
A 19-year-old woman presents with a 2-day history of continuous middle and left lower quadrant pain without fever or chills. What is the likely diagnosis based on the US findings shown below?
Right ovary
Left ovary
US findings:
The left ovary is avascular, enlarged, and displaced toward the midline, with multiple sub-endothelial cysts The right ovary is normal in position and appearance
Answer: Left ovarian torsion.
This is a surgical emergency!
Left ovary
Sagittal midline
Uterus
Slide16Case 4: Ovarian Torsion
Half of cases occur before menarche
Pathophysiology:
Ischemia of the ovary and/or fallopian tube due to twisting of the vascular pedicle; may lead to hemorrhagic infarction
Signs and symptoms:Acute excruciating abdominal pain; may be intermittent with torsion and detorsionNausea, vomiting, and adnexal tendernessLow-grade fever and/or a mildly elevated WBC count may or may not be presentUS is the diagnostic imaging method of choice.
Gray-scale US findings:Unilateral enlarged ovary, often in midline position
Peripheral
subendothelial
cysts
Heterogeneity of central
stroma
Fallopian tube thickening
Lead point for torsion (
eg
, cyst or tumor) may or may not be seen
Pelvic free fluid and/or
hemoperitoneum
Color Doppler US findings:
Whirlpool sign due to twisted pedicle
Ovary may show
tardus
parvus
waveform
Decreased or absent diastolic flow, absent venous flow
Increased flow during
detorsion
IMPORTANT: Normal blood flow does not exclude torsion.
Gray-scale US findings are more reliable than color Doppler US findings.
Whirlpool sign
Tardus
parvus
waveform
Slide17Case 5
A 38-year-old woman presents with progressively worsening left lower abdominal quadrant and suprapubic pain. What is the likely diagnosis based on the US findings shown below?
US findings:
Heterogeneous,
hypoechoic
, solid intrauterine massLocation of mass correlated to region of pain
Heterogeneous solid mass
No internal flow on Doppler images
Answer:
Necrotic uterine fibroid
Uterus: point of maximal pain
Uterus: point of maximal pain
Slide18Pathophysiology: benign smooth-muscle neoplasm
Fibroids increase in size and number with increasing patient age and involute after menopause
Often asymptomatic
Signs and symptoms depend on
Type and location of fibroid:
Pedunculated: torsion/ischemiaSubmucosal: abnormal uterine bleeding Cornual: tubal obstruction Size and growth: Fast growth of fibroid depletes blood supply, leading to fibroid degeneration and necrosisAnterior position may lead to urinary urgencyPosterior position may lead to constipationIf patient is pregnant: Fetal loss, premature labor, and malpresentation may resultCase 5: Necrotic Fibroid
US is the imaging method of choiceGray-scale US findings:
Well-defined focal mass,
hypoechoic
to myometrium
Poor through-transmission with acoustic shadow
Heterogeneous
echotexture
Color Doppler US findings:
Blood flow from periphery to center
Wheel spoke–like pattern
Low-resistance waveform
Pedunculated
lesions with bridging vessels connected to the uterus
Hypoechoic
to
myometrium
Bridging vessels
Slide19Left ovary
Case 6
A 38-year-old woman undergoing therapy with clomiphene citrate for infertility presents with abdominal pain. What is the likely diagnosis based on the findings shown below?
US findings:
Bilateral enlarged ovaries
Multiple large cysts with evidence of hemorrhage
Large amount of free fluid in the pelvis and extending superiorly
US findings and clinical history are diagnostic.
Right ovary
Free fluid in right upper quadrant
Answer:
Ovarian
hyperstimulation
syndrome.
Liver
Hemorrhage
Slide20Case 6: Ovarian Hyperstimulation Syndrome
Pathogenesis:
Most commonly iatrogenic, from use of ovarian stimulant drug therapy for infertility
Can also occur spontaneously in pregnancy
Ovarian enlargement with extravascular accumulation of exudates
Signs and symptoms:Weight gain, ascites, pleural effusion, intravascular volume depletion, oliguriaPain, nausea, vomitingUS findings: Distended luteal cysts of varied sizeWheel spoke–like appearance of ovarian stromal tissue, produced by cysts surrounding central ovarian tissueIn cyst rupture: debris, retractile clot, and fluid-fluid levelsIn torsion: asymmetric blood flow
Corollary magnetic resonance (MR) imaging is necessary if the ovaries are asymmetric in size and an underlying tumor is suspected.
“Wheel spoke”
Ovaries
Ascites
Slide21Case 7
A 28-year-old woman presented 3 weeks postpartum with right lower quadrant pain and tenderness. US demonstrated a normal uterus and ovaries. What is the likely diagnosis based on the CT findings below?
CT findings:
5-mm-diameter filling defect within the inferior vena cava (IVC)
Enlarged right ovarian vein with a central filling defect extending to the level of the right ovary
Answer:
Ovarian vein thrombosis
Aorta
Aorta
IVC
Ureter
Right ovarian vein with filling defect
Right ovarian vein with filling defect
Filling defect
IVC
Slide22Pathophysiology:Rare entityAssociated with ascending postpartum ovarian vein thrombophlebitis
Most cases occur within 10 days after delivery
May occur after pelvic surgery
Signs and symptoms:
Fever
Right lower quadrant abdominal painPalpable tubular abdominal massCase 7: Ovarian Vein ThrombosisCT is the diagnostic imaging method of choice.CT findings: Enlarged ovarian veinLow-attenuation filling defect within central lumenEnhancing wallCan extend into IVCUS findings:Tubular mass lateral to aorta or IVC
Variable echogenicity of thrombusPartial or absent flow within the vein
Slide23Case 8
A 28-year-old woman presents to the emergency department with severe abdominal pain, nausea, vomiting, and diarrhea. What is the likely diagnosis based on the findings shown below?
Power Doppler US
Gray-scale US
US findings:
Diffusely homogeneous cystic structure with internal
hypoechogenicity
and no internal blood flow
Normal surrounding ovarian tissue
Small amount of free fluid within the pelvis
CT findings:
Thick-walled, slightly irregular, low-attenuation cystic structure in the region of the left ovary
Answer:
Endometrioma
Slide24Case 8: Endometrioma
Endometriosis:
Presence of endometrial glands and
stroma
outside the uterus
Typically implanted on the surface of the ovary, uterine suspensory ligaments, uterus, and/or fallopian tubesEndometrioma (“chocolate” cyst):Thick-walled, complex cyst with internal debris the color of chocolate Signs and symptoms:Chronic pelvic pain, dysmenorrhea, dys-pareunia May be estrogen dependent or cyclic in nature Irregular bleedingInfertilityMany cases are asymptomaticUS is the diagnostic imaging method of choice
US findings: Endometrioma:
Thick-walled complex cyst with diffuse, homogeneous, low-level internal echogenicity
Increased through-transmission
Punctate calcifications within wall
No internal blood flow
Peritoneal plaque:
Hypoechoic
structure
May mimic free fluid
Tethering and kinking of bowel wall
May be hypo- to moderately vascular
MR imaging is needed for masses with an indeterminate US appearance or apparent peritoneal seeding.
Calcification
Endometrioma
of
C
- C-section scar
MR T1 FS + C
Slide25Case 9
A 36-year-old woman with increasing abdominal pain, fever, nausea, and vomiting presented for clinical evaluation. Cervical motion tenderness was found at the physical examination. What is the likely diagnosis based on the
transvaginal
US
findings shown below?
US findings:Loss of right ovarian architecture due to replacement by a heterogeneous fluid collectionEnlarged, edematous left ovaryTubular complex fluid-filled structures adherent to the bilateral adnexaComplex fluid collection within the pelvisIncreased echogenicity of adjacent fat
Right side
Left side
Complex fluid
Right side
Left side
Fallopian tubes with pus
Abscess
Answer:
Pelvic inflammatory disease (PID) with right
tubo
-ovarian abscess and left
tubo
-ovarian complex
Ovary
Slide26Ascending bacterial infectionMost common causes: Chlamydia
and
Neisseria
gonorrhoeae
Involves cervix, uterus, fallopian tubes, and ovaries
Definitions:PID Upper urinary tract infectionPyosalpinx Pus-filled fallopian tubeTubo-ovarian complex Ovary adherent to but visually separable from fallopian tube Tubo-ovarian abscess Abscess of ovary and fallopian tube, ovary no longer identifiableSigns and symptoms:Pelvic pain with or without cervical motion tenderness, fever, vaginal discharge, and elevated WBC countClinical history is essential for the diagnosis of PIDHelps differentiate it from a neoplasm
Case 9: Pelvic Inflammatory Disease
Slide27Case 9: Pelvic Inflammatory Disease
Free fluid
Adnexa/
fallopian
tube
Adnexa/
fallopian tube
Transvaginal
US is the imaging modality of choice
Gray-scale findings:
Fallopian tube: Distended with complex layering of fluid with or without gas; thickened walls; increased vascularity; tubes extend posteriorly and may fold inward, causing incomplete
septation
Ovary:
PID: Enlarged ovary, increased number and size of follicles
Tubo
-ovarian complex: Separate, enlarged ovary adherent to tube
Tubo
-ovarian abscess: Ovary unrecognizable; complex adnexal mass with or without
pyosalpinx
Complex pelvic fluid with pus
Increased echogenicity of pelvic fat
Color Doppler findings:
Increased flow in wall of fallopian tube and involved ovary
Low-resistance waveforms
Corollary imaging with CT is needed when pelvic findings are extensive
CT findings:
Infection may involve the upper abdomen
Look for
hydronephrosis
secondary to compression of the ureters
Slide28Case 10
A 33-year-old woman with known left ovarian cysts presented to the emergency department with acute left lower quadrant pain. She had no vaginal bleeding, fever, or chills. Her last men-
strual
period was 5 weeks earlier, and the result of a pregnancy test was positive. What is the likely diagnosis based on the US findings?
US findings:
Thickened endometrium with central fluidHeterogeneous mass in the left adnexal area with no normal left ovary identifiedInternal flow within the massSmall amount of pelvic peritoneal fluid with debris, possibly hemorrhagicUterine decidual reaction
Fluid in endometrial canal
Uterus
Arterial waveform
Mass
Decidual
reaction
Answer:
Pelvic mass with an appearance suggestive of a ruptured ectopic pregnancy (the diagnosis in this case was con-firmed at surgery)
Blood
Mass
Slide29Case 10: Ectopic Pregnancy
Pregnancy located outside the endometrial cavity
May or may not rupture
Often manifests 5–6 weeks after the last menstrual period
Risk factors:
Prior ectopic pregnancy, history of tubal disease and/or PID, use of an IUD, infertility treatment, prior pelvic surgerySigns and symptoms:Acute pain, vaginal bleeding, palpable adnexal mass, peritoneal signsPregnancy test is essential for diagnosisIf the result of a pregnancy test is not clear, quantitative measurement of the beta human chorionic gonadotropin (ß-hCG) level and follow-up US are recommendedAn elevated ß-hCG level in the absence of an intrauterine pregnancy is indicative of ectopic pregnancy until proven otherwiseUS is the imaging method of choiceGray-scale findings:Uterus:No intrauterine pregnancy (intrauterine sac should be visible by 5 weeks gestation, or once ß-
hCG levels are between 1000 and 2000 mIU/mL)
Pseudosac
(fluid within the endometrial cavity)
Decidual
reaction
Fallopian tube:
Ringlike
mass separate from the ovary (may have yolk sac and/or embryonic pole)
Amorphous mass secondary to blood clot
Free pelvic fluid with debris suggestive of a ruptured sac
Scan upper abdomen for extent
Color Doppler findings:
Ring of color may be seen around an adnexal mass but is not always present
Slide30Case 11
A 19-year-old woman presents to the emergency department with a sudden onset of right lower quadrant pain and is found to have an elevated WBC count. Physical examination reveals lower abdominal pain and cervical motion tenderness. The patient denies experiencing nausea, vomiting, a fever, chills, dysuria, or vaginal bleeding. What is the likely diagnosis based on the US findings?
US findings:
Normal right and left ovaries, with normal flow
Normal-appearing uterus
At the point of maximal tenderness: a dilated, noncompressible, hyperemic appendix
Important:
Evaluate the site of pain!
Right ovary
Left ovary
Uterus
Point of maximal pain
Hyperemia
With compression
No compression
Answer:
Acute appendicitis
Slide31Acute obstruction of the appendicular lumen Causes distention, ischemia, superimposed infection, and possibly perforationSigns and symptoms:
Abdominal pain that begins in a
periumbilical
location and migrates to the right lower abdominal quadrant
McBurney
point tendernessNausea, vomiting, diarrhea, and feverCase 11: AppendicitisUS is the imaging method of choice for evaluating children but is often nondiagnosticUtility of US versus CT as the primary imaging method for evaluation of adults is debatedUS findings:Echogenic appendicolith with acoustic shadowNoncompressible, blind-ended tubular structure with a diameter of more than 6 mmFluid collection or abscess in right lower abdominal quadrant
Important:
Nonvisualization
of the appendix at imaging does not necessarily allow the exclusion of appendicitis from the differential diagnosis.
Slide32Case 12
A 32-year-old woman presents to the emergency department with left lower quadrant abdominal pain since the morning. Pelvic examination reveals cervical motion tenderness and adnexal tenderness. What is the likely diagnosis based on the US findings shown below?
Uterus
Right ovary
Left ovary
Thickened sigmoid colon
US findings:
Normal appearance of bilateral ovaries and uterus
Circumferential thickening and hyperemia of the sigmoid colon wall in the left lower quadrant
Hyperechoic
, inflamed fat
Answer:
Diverticulitis of the sigmoid colon
Hyperechoic
fat
Slide33Inflammation with or without perforation of colonic diverticulaMost often involves the sigmoid colonSigns and symptoms:
Left lower quadrant colicky pain, tenderness, palpable mass, fever, change in bowel habits
CT is the imaging method of choice
US findings should be further evaluated with CT
Case 12: Diverticulitis
Inflamed sigmoid colon
US findings:Bowel wall thickening to more than 4 mm
Diverticular pouches
Pericolic
inflammation
Pericolic
fluid collection or abscess
Hyperemia of
pericolic
fat
Slide34Case 13
A 43-year-old woman presents to the emergency department with an acute onset of sharp intermittent pain in the right lower abdominal quadrant with associated nausea and vomiting. The patient denies experiencing a fever or chills. What is the likely diagnosis based on the imaging findings below?
Thickened terminal ileum
Dilated small bowel
US findings:
Multiple loops of fluid-filled small bowel throughout the abdomen
CT findings:
Thickened terminal ileum
Multiple loops of dilated small bowel
Free fluid within the pelvis
Answer:
Inflammatory bowel disease (Crohn disease)
Slide35Chronic inflammatory disease of the gastrointestinal (GI) tractCrohn disease:Noncontiguous involvement of the entire thickness of the mucosa throughout the GI tract, from mouth to anus
Ulcerative colitis:
Contiguous involvement of the GI tract, typically starting at the rectum and continuing proximally; superficial mucosal involvement
Signs and symptoms:
Abdominal pain, diarrhea, anorexia, weight loss, low-grade fever, muscle aches, fatigue
Case 13: Inflammatory Bowel DiseaseEndoscopy and colonoscopy are the diagnostic techniques of choiceDirect visualization of bowel lesionsBiopsy to confirm diagnosisImaging may be used for further workup:CT and MR imaging findings: Bowel wall thickening, increased vascularity, abscess, fat stranding, lymphadenopathyFluoroscopic findings: Luminal narrowing; cobblestone-like appearance of bowel wall, mucosal edema, mucosal ulcers, fistulas, stricture, skip lesions, abnormal appearance of haustra
US findings: Bowel wall thickening
Slide36Case 14
A 26-year-old woman presents to the emergency department with severe right lower quadrant abdominal pain disproportionate to pressure applied during palpation. What is the likely diagnosis based on the US findings shown below?
Stone
Right kidney
Hydronephrosis
Right ovary
Uterus
Left ovary
Bladder
US findings:
Normal right and left ovaries
Normal uterus
Ureteral stone in the right
uretero-vesical
junction (UVJ)
Hydronephrosis
of the right kidney
Answer:
Stone obstructing the right UVJ
Slide37Solid concretion or crystal aggregation formed in the renal collecting systemMay or may not be obstructive
When
nonobstructive
, may be asymptomatic
Signs and symptoms may be dependent on location and may include:
Kidney: flank pain, feverUreter: acute colicky pain secondary to ureteral peristalsis, radiating to the groinBladder: dysuria; dull or sharp pain radiating to the buttocks, perineum, and genitalsCase 14: Renal StoneCT is the imaging method of choiceNon–contrast-enhanced CT allows direct visualization of stones, although matrix and indinavir stones might not be seenSecondary CT findings:“Soft-tissue rim” sign secondary to ureteral wall edema due to the presence of a stoneHydronephrosis
, hydroureter, perinephric and/or periureteral inflammatory stranding
UVJ edema surrounding a calculus
US findings:
“Bright”
hyperechoic
focus
Acoustic shadow often accompanies a stones larger than 5 mm in diameter; twinkle artifact allows detection of smaller stones
Depiction of stone is best in kidney or at UVJ, poorest in
midureter
Presence of ureteral jet from UVJ into bladder allows exclusion of obstructing stone
Stone
Twinkle artifact
Slide38ConclusionsUnderstanding the benefits and limitations of US for evaluating the gynecologic causes of acute female pain is extremely important in critical care service.
Recognize the benefits and limitations of US.
Know when to use other modalities, such as CT and/or MR imaging, for corollary studies.
Knowledge of pelvic US is important to definitively diagnose the cause or to provide a succinct differential diagnosis allowing appropriate treatment of acute pelvic pain in female patients while minimizing radiation exposure and optimizing patient care.
Slide39Bhatt S, Dogra VS. Doppler imaging of the uterus and adnexae
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Clin
2006;1(1):201–221.
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