Peritoneal pelvic adhesions in women: frequently advocated in repetitive addominal pain but not always demonstrated and classified by Imaging.

Transcription

1 Peritoneal pelvic adhesions in women: frequently advocated in repetitive addominal pain but not always demonstrated and classified by Imaging. Poster No.: C-2156 Congress: ECR 2012 Type: Educational Exhibit Authors: M. V. Guzzetta, G. Guzzetta, G. Rosa, G. P. Feltrin ; Padua/IT, PADOVA/IT, Padova/IT Keywords: Obstruction / Occlusion, Hysterosalpingography, MR, Fluoroscopy, Genital / Reproductive system female, Abdomen DOI: /ecr2012/C-2156 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Learning objectives Among significant causes of pelvic adhesions, the most frequently are: postsurgical procedures, endometriosis and peritoneal inflammation disease. The adhesion consequences are: displacement of utero-vaginal structures, angulated bowel loops, hydrosalphyngs, trapping of the peritoneal fluid or unnatural distribution of ascites, adhesive strantding anatomic structures and possible infertility. The majority of these findings are detectable in MR studies. Direct adhesion are visible by low signal intensity, which obscures organs interface. Nevertheless the salphilges or ovarian-tubar-utero obstructions are really demonstrated by Isterosalpingography (HSG). Our aim is to evaluate the findings of adhesions including the infertility causes by MR and HSG studies. Background We have analyzed the adhesion findings in a series of pathologies, frequently associated with adhesions. 79 women underwent to abdominal MR and or HSG for abdominal pain, infertility or endometriosis. T1, T2, Fat suppressor, STIR sequences were explored in MR studies, after filling the vagina with watery gel. HSG was realized after uterus catheterization with usual balloon catheter and the cavity was filled until drip of the contrast media (c.m.) in peritoneum, even manually forcing the injection when one or both sides appeared closed (Fig.1, Fig.2, Fig.4, Fig.5, Fig.6). The exam was obtained in oblique position in order to favour the tubal filling or flushing, and in prone position to evaluate the free diffusion of c.m. in the peritoneal cavity (Fig.3). This later manoeuvre was very important and crucial to evaluate all peritoneal adhesions and to classify them. Images for this section: Page 2 of 17

3 Fig. 1: HSG opens tubes; extended diffusion of c.m. in peritoneum, with large filling of the Douglas compartment. Page 3 of 17

4 Fig. 2 Page 4 of 17

5 Fig. 4: HSG: with few ml of c.m.,the tubes appeared open, but with more c.m. the left tube closed and dilated (sactosalpinx). Page 5 of 17

6 Fig. 5: The c.m. diffused in the pelvic peritoneal cavityonly through right salpinx open. Page 6 of 17

7 Fig. 6: AO view: left sactosalpinx. Page 7 of 17

8 Fig. 3: In prone position, the c.m. diffused freely. Page 8 of 17

9 Imaging findings OR Procedure details The detections of these lesions in case of peritoneal and extra-peritoneal endometriomas were obtained by MR. Only the major associated adhesions were detected by MR with fibrosis or thickening of low signal stripes. The stranding of the anatomy or organs are also detected, but the fixed positions less than with HSG. On the contrary, at the HSG, the findings were: 1- Intestinal loops anglulation (Fig.7, Fig.11); 2- fixed position of tubes or uterus not modified by changed position of the patient; 3- large involvement of the organs or loops suggesting their peritoneal fibrosis (Fig. 9) 4- obstructed salphilges (Fig.7, Fig.8, Fig.11); 5- not dropping in peritoneum of c.m (Fig.7, Fig.8, Fig.9). 6- dropping of the c.m. in peritoneum but not diffusing within, even in changed decubitus, in other words the formation of peritoneal pouches (Fig.7). The total signs of peritoneal adhesions with resulting block or stranding of organs were observed in 13 out 79 patients and the adhesions described at point n. 2 and 6 in 29 patients (Fig.10, Fig.12, Fig.13). Images for this section: Page 9 of 17

10 Fig. 7: HSG: The left salpinx is closed and dilated in sactosalpinx. The c.m., dropped in peritoneum, is free diffused from right tube towards the Douglas and left side, where it revealed a peritoneal pouch (lower as regards uterus) dued to adhesions of left side, even a cause of stopped left salpinx. Page 10 of 17

11 Fig. 8: HSG: dilated right salpinx (as sactosalpinx) but open with passage of c.m. in peritoneum. The left tube is closed. Page 11 of 17

12 Fig. 9: The same patient of Fig.8 in LAO oblique view. The retroverted uterus shows a right sactosalpinx, but open distally. The left tube remains closed. Page 12 of 17

13 Fig. 10: HSG: bilateral opened tubes with free diffusion of c.m. On left side the c.m. went around to the left ovary. Page 13 of 17

14 Fig. 11: HSG: the left salpinx is closed (see the myometrial diffusion of c.m. on left) and strands in lower position. Page 14 of 17

15 Fig. 12: HSG. the same patient of Fig.11: by soft guide, the left tube was reopened until peritoneal cavity. Page 15 of 17

16 Fig. 13: After the manoeuvre, the filling of the left tube shows opening with drops of the c.m. in peritoneum. Page 16 of 17

17 Conclusion MR Imaging has limitated usefullness to detect an accurate diagnosis of adhesions when the fibrosis is not extended or obscuring organs interface. The specific signs of pelvic organs blockade are uniequivocally established by HSG by c.m. entrapped in spite of free peritoneal diffusion. Consequently only for infertility, not only linked to endometriosis, the HSG is recommend. Personal Information References - Valentini A.L., De Vivo D., La Vecchia G., Colavita N., Vicenzoni M. Il decubito prono in isterosalpingografia. Radiol Med 70: Page 17 of 17