Scope of the Problem. Scope of the Problem. Acute Pelvic Pain. Advantages of Pelvic Sonography. Acute Pelvic Pain: Lessons Learned from the ED

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1 Acute Pelvic Pain: Lessons Learned from the ED Anna S. Lev-Toaff, MD FACR Department of Radiology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Leading Edge in Diagnostic Ultrasound Atlantic City, 2010 Scope of the Problem Pelvic pain in women accounts for 10-40% of all gynecologic visits. Most patients with gyn emergencies complain of pelvic pain w or w/o vaginal bleeding. The first step in women of reproductive age is establishing pregnancy status. In pregnant women, ectopic pregnancy and abnormal pregnancy is the main concern. Advantages of Pelvic Sonography Both transabdominal and transvaginal approaches can be valuable. Lack of ionizing radiation, easily available. Superior visualization of female genital tract compared to CT. Direct extension of the examining hands by direct contact with the patient, she will guide you to the focus of pain. Scope of the Problem The origin of acute pelvic pain (less than 1 month) in the non-pregnant patient may be: Gynecologic (PID, Functional ovarian cyst, Ovarian endometriomas, Adnexal torsion) Gastrointestinal (Acute appendicitis, Acute sigmoid diverticulitis, Crohn s disease, Abdominal wall hernia, Epiploic appendagitis) Urologic (Lower urinary tract infection and Ureteral calculi) Acute Pelvic Pain The objectives of this presentation are to familiarize the practicing radiologist with the entities most likely to be encountered from the emergency department. To demonstrate the primary role of pelvic sonography in diagnosing these conditions. 30 year old woman, s/p gastric bypass and abdominoplasty with severe rlq pain. Initially read as Meckel's or stump appendicitis, taken to OR. Note: enhancing rim around fluid collection

2 Is the LMP relevant to correct interpretation of a CT as it is in US? LMP: 2 weeks ago What was found at surgery? Note: Fluid in cul de sac What was found at surgery? 1. Stump appendicitis 2. Meckel s diverticulitis 3. Corpus luteum right ovary 4. Adnexal torsion LMP: 2 weeks ago 3. Corpus luteum (but wrong way to making dx) Computed tomography of corpus luteum cysts J Computed Assist Tomogr 2004; 28:340 Thick crenulated or hyperdense wall <3cm diameter Free fluid recognition of these CT findings should prevent misinterpretation or inappropriate management. The following case demonstrates the better approach to evaluating a young woman presenting to the ED w acute pelvic pain and 2

3 25 year old woman, sharp shooting pelvic pain, difficulty taking deep breaths, started suddenly p sexual intercourse, HCG (-).( 25 year old woman, sharp shooting pelvic pain, difficulty taking deep breaths, started suddenly p sexual intercourse, HCG (-).( Note: echoes in fluid lo ro lo ro Large heterogenously echogenic structure w/o color flow in right adnexa Sudden sudden onset, nature of pain and neg beta-hcg, suggests bleeding or torsion With normal size ovaries, torsion very unlikely (torsion rarely associated w so much fluid) Given the clinical picture and sonographic findings, transvaginal ultrasound not necessary and CT avoided. 3

4 Lessons of this case Look for and learn to recognize hematoma on ultrasound, esp in presence of free fluid Hematoma may blend with surrounding pelvic fat/bowel; obscure corpus luteum cyst Even if pelvic ultrasound ordered, check all four quadrants of the abdomen to assess for presence and amount of bleeding Useful for ruptured cyst, ectopic pregnancy, trauma, post-op. op. Acute PID Acute ascending infection -- uterus, tubes, ovaries and pelvic peritoneum; caused by N. gonorrhea, Chlamydia, co-infection w other bacteria. Typically presents during/after menses. Clinical manifestations: lower abdominal and pelvic pain, vaginal discharge, fever +/- nausea, vomiting and malaise, leukocytosis. Exam: bil. adnexal tenderness, cervical motion tenderness, purulent cervical discharge. Acute PID early sonographic signs Free pelvic fluid ± low level echoes -- PUS Endometrial fluid Hyperemia of uterus Indistinct serosal surface of uterus Increased echogenicity of pelvic fat Acute PID early sonographic signs Acute oophoritis ovaries enlarged with multiple small follicles; ill-defined outer margins Acute salpingitis swollen fallopian tubes with thickened mucosal folds, tube is now readily visualized separate from the ovary Acute Salpingitis early US signs Tube distinctly recognized separate from ovary with thickened mucosal folds Acute PID progression to pyosalpinx Inflamed distal tube becomes occluded; seen as thick-walled pear-shaped structure filled with dependant low level echoes; may see a fluid-fluid level. sagittal ovary Marked tubal hyperemia Color Doppler: hyperemia of thickened tubal wall, No longer separable from ovary (tubo-ov complex) Posterior through transmission reflects fluid tubal content. transverse 4

5 Acute salpingitis fluid/fluid levels Acute salpingitis cogwheel sign: thickened blunted mucosal folds sagittal Acute PID Tubo-ovarian ovarian Abscess Large size of cystic mass demonstrated in comparison to uterus, mass inseparable from uterus Multilocular cystic adnexal mass abutting posterior uterus, extending into cul de sac. Complex material (PUS) fills thick-walled cysts. transverse ut Acute PID Acute PID could be confidently diagnosed in most cases by a gynecologist based on clinical and laboratory data. Imaging would be reserved for patients who failed medical therapy, in order to assess for TOA. In our current reality, many patients are referred by ER clinicians for an imaging study as an early diagnostic tool. Failure to detect the subtle early sonographic findings may lead to additional imaging with CT and potentially to unnecessary surgery. Functional ovarian cysts- Follicular Follicular cysts develop because of failure of involution of a developing follicle; up to 4cm. While usually asymptomatic, may lead to pain due to leakage, torsion or hemorrhage. FOLLICULAR CYSTS Extremely common Physiologic cyst Usually 5 cm Lined with granulosa cells Cyst forms when follicle fails to rupture or regress 5

6 Functional ovarian cysts- Corpus Luteum Cyst Caused by continued growth of the corpus luteum after ovulation; typically cm. Typically CLC cause local pain and delayed menses (1-2 2 months) due to progesterone secretion. May lead to adnexal torsion with severe pain Or, may rupture causing hemoperitoneum. Most hemorrhagic cysts are CLC that have bled internally. Sonography of Hemorrhagic Cysts Appearance depends on extent of bleeding and stage at imaging Smooth unilocular cyst filled with low level echoes Septated cyst with irregular walls Cyst containing organized blood may simulate solid mass Organizing blood may appear as strands of linear density (lace-like like pattern) or bizarre shapes of retracting clots within a cyst. In all cases, there should be no internal vascularity but the walls of an HC are often vascular. Hemoperitoneum degree may vary, may need to use TA US to assess extent. Hemorrhagic Cyst lacelike pattern HOC uterus Unilocular cyst w retracting clot Two months later - resolved Blood clot Clot echogenic retractile HOC HOC No internal vascularity Most HOC resolve in 2 mos-f/u in 1st 10 days of cycle 6

7 HOC large hemoperitoneum Endometrioma CT: non-specific o o 36 yo acute LLQ pain w/o fever or elevated WBC. Hx of cyclical pelvic pain during menses. LO contains two locules full of low-level echoes, no internal vascularity, increased posterior sound through transmission. LO Bilateral ovarian endometriomas Rupture on L with hemoperitoneum in CDS RO LO 3. Endometriotic implants in a scar Adnexal Torsion Caused by twisting of the adnexa around its vascular pedicle (ovarian a, ov branch of uterine a) with vascular impairment. Majority of cases tube AND ovary involved. If torsion not relieved: hemorrhagic infarction and necrosis and peritonitis. Early diagnosis and treatment critical Pre-existing existing conditions (cyst, neoplasm 50-80%; previous surgery 50%) Reproductive years, PM in 24% Adnexal Torsion Acute unilateral pelvic pain of sudden onset, nausea, vomiting, elev WBC. Adnexa extremely tender and enlarged on palpation and w TV probe Because of various degrees of torsion and spontaneous torsion/detorsion presentation may be atypical or intermittent 7

8 Sonographic Findings Variable, depend on duration and degree of torsion. Intermittent torsion causes variable findings on color and spectral Doppler. Nature of underlying adnexal mass influences findings. Ovary enlarged, freq abnormally located above/behind uterus Classic appearance of enlarged ovary w prominent heterog stroma,, small peripheral follicles seen in minority. TA TV 35 year old woman - sudden onset of pelvic pain RO At surgery, ro torsed 3-4 times Cyst LO C u CT w/o IV contrast: uterus deviated to left C u Unusual case: Paraovarian cyst (C) as underlying cause of left ovarian torsion Normal RO Enlarged LO Unusual case: Paraovarian cyst (C) as underlying cause of ovarian torsion C u C u Fluid CDS 8

9 Acute Appendicitis Classically: presents with anorexia, low-grade fever and diffuse peri-umbilical pain. Within hrs (usu( 4-6) pain localizes to RLQ Variations due to variable location of appendix: Retrocecal (flank or back pain) Pelvic (suprapubic( pain) Malrotation of colon or mobile cecum (pain variable) Acute Appendicitis On exam RLQ tenderness plus rebound and guarding Leukocytosis: : usually moderate (10-18,000) 18,000) If appendix perforates, more severe and diffuse RLQ pain. In women of reproductive age, diagnostic error is greater than in men up to 40% because GYN conditions may simulate acute AP Acute Appendicitis -US Normal appendix tubular blind-ending structure arising from base of cecum,, on same side as IC valve (or ileum leading to ICV). Visualization in 0-82% 0 (CT %) reflecting operator expertise and location (out of field of view). Abnormal appendix greater than 6-7mm 6 in cross section (serosa( to serosa). Normal appendix aperistaltic (unlike small bowel), compressible on US, surrounded by homogeneous non-inflamed fat often w visible gas bubbles in lumen. Acute Appendicitis -US Inflamed appendix is enlarged, surrounded by hyperechoic inflamed fat, and hyperemic on CDS; presence of fecalith highly suggestive. In women, TVS imp. complementary tool to RLQ compression sonography; ; when CT is indeterminate. When appendix extends inferomedially into right adnexal region or CDS (21% women) ideally imaged by TVS May not be able to compress or see entire AP, but high resolution allows ID of bowel wall layers lack of continuity of echogenic submucosa suggests mural necrosis, impending perforation. Acute Appendicitis on TVS Acute Appendicitis on TVS- marked hyperemia Hyperemia RO UT Trv diameter 8mm Prox ap Appendiceal tip 9

10 lack of continuity of echogenic submucosa suggests mural necrosis, impending perforation. Perforated appendix loss of bowel wall signature transabdominal 65 year old women w RLQ pain- now what? appendix? ovary What is the next step? terminal ileum Pelvic appendix accessible by TVS for diagnosis & abscess drainage 4.Transvaginal US Appendicitis in Women * Tip Appendicitis * collection 1. Barium enema 2. Follow-up CT in 24 hours 3. Pelvic MRI 4. Transvaginal sonography fecalith 1.8cm Tip of appendix * Acute Sigmoid Diverticulitis Colonic diverticulosis affects 10% of patients over the age of 45. However, cases in their 30 s s are not unusual. Most common location sigmoid colon Symptoms: pain LLQ mild-moderate, moderate, anorexia (±nausea),( diarrhea or constipation, low grade fever Tenderness LLQ/suprapubic (occ palpable mass) Acute Sigmoid Diverticulitis Partial colonic obstruction (edema, inflammation, spasm) complete obstruction 10% Perforation of inflamed diverticulum may occur w local inflammation/pericolic abscess. Fistula to bladder (or urinary symptoms) less common in women w uteri. Free perforation leading to free air outside sigmoid mesocolon is rare. 10

11 Imaging in Acute Sigmoid Diverticulitis Dx usually straightforward most commonly with urgent CT. Findings: stranding pericolic fat, thickened sigmoid, presence of diverticula Imaging in Acute Sigmoid Diverticulitis Dx can also be made on US, when pt is younger or ASD not suspected. TVS helpful when inflamed sigmoid deep in pelvis: long segment of thick colonic wall, prominent outer hypoechoic muscularia propria Inflamed diverticulum seen as bright echogenic focus with shadowing projecting beyond margin of thick colon. Hyper-echogenic echogenic pericolonic fat indicates inflammation on US. Sigmoid Diverticulum - TVS Sigmoid diverticular abscess - TVS Abscess Thick wall Sigmoid wall Echogenic fat Assess for location of tenderness w probe TVS indispensible tool guiding drainage of abscess in women Crohn s Disease Chronic transmural inflamm; ; any part of gut; y.o.. typical age, multiple remissions/exac exac Small intestine involved 80% (TI most common) Most present w chronic diarrhea, pain, wt loss, fever Adherent bowel loops form masses, fistulae, obstruction/perforation, abscess Crohn s Disease One- third of patients w ileocecal Crohn s present with initial symptoms so acute, mimicking other acute causes of abdominal/pelvic pain. Can mimick acute appendicitis, PID, etc. 11

12 Imaging in acute Crohn s Disease Ultrasound may be performed to evaluate acute presentations of lower abd/pelvic pain. US findings: transmural bowel wall thickening, prominent echogenic submucosal layer, echogenic fat reflects mesenteric inflammation, enlarged mesenteric lymph nodes. US useful to distinguish between phlegmon vs well defined drainable abscess. TVS effective when inv segment is in true pelvis, for guiding transvaginal drainage Crohn s Pelvic Ileum transmural bowel wall thickening prominent echogenic submucosal layer Acute Crohn s Disease Ileal thickening Thick edematous small bowel 32 yo female hx of Crohns disease. Prior CT shows findings of ileocecal Crohns Ileocecal junction; mesenteric stranding abscess Surrounding echogenic fat One month later acute RLQ pain and fever Urinary Tract UTI frequent cause of acute pelvic symptoms Frequent urination, dysuria, hematuria,, lower abdominal and pelvic pain. Pyuria in UA Imaging is usually unnecessary in acute UTI. In young women, US rather than CT, is recommended as initial evaluation in patients w increased risk: DM, Immunocompromised, pregnancy: assess for calculi, diverticuli, bladder wall thickening, debris, post-void residual, rarely tumors. Urinary Tract Ultrasound Technique Bladder evaluation with TVS requires small- moderate amount of urine. Angle TV probe anteriorly Partial withdrawal of probe to evaluate bladder base and urethra. Overdistended bladder may obscure trigone,, distal ureters and UVJ. Intramural and distal ureter located sl anterior and lateral to upper vagina: dilated ureter seen as elongated tubular structure entering bladder in oblique course. 12

13 Urinary Tract - Ultrasound Calculi in ureter presents with typical renal colic Urinalysis initially may be negative if ureter completely obstructed Later, UA may show large #s of RBC and crystals. Distal ureteral calculi may present with pelvic pain and be recognized on pelvic US. In obese/pregnant women and those w contrast contraindicationws,, TVS helpful to locate distal ureteric calculi TRV Calculus to rt of ut UT 34 yo acute RLQ pain; rule out hemorrhagic cyst SAG Shadowing calc Calculus missed on CT Dilated ureter What s s significance of a negative pelvic US in acute pelvic pain? Pelvic pain improved or resolved in 77% of 86 women. In a woman w acute pelvic pain, a negative pelvic US has an excellent negative predictive value for resolution. Harris RD, Holtzman SR, Poppe AM, Radiology 2000; 216, 440. Conclusions Acute pelvic pain is one of the most common acute presentations in the ED. In women, GYN, GU, and GI etiologies may mimic each other. In our current working environment, definitive diagnosis is expected while the pt is in the ER. Use of pelvic sonography (inc TVS) should be maximized and used to its full capacity in order to limit the use of CT. 13

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