Acute and Chronic Pelvic Pain Disorders 17

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1 Acute nd Chronic Pelvic Pin Disorders 355 Acute nd Chronic Pelvic Pin Disorders 17 Rosemrie Forstner nd Astrid Schneider CONTENTS 17.1 Introduction Gynecologicl Cuses of Pelvic Pin Pelvic Inflmmtory Disese Hydropyoslpinx Differentil dignosis Tuoovrin Ascess Differentil dignosis Vlue of Imging Ovrin Torsion Differentil dignosis Dignostic Vlue Ectopic Pregnncy Differentil Dignosis Vlue of imging Nongynecologicl Cuses of Pelvic Pin Pelvic Congestion Syndrome Differentil Dignosis Vlue of Imging Ovrin Vein Thromosis Differentil dignosis Vlue of Imging Appendicitis Vlue of Imging Diverticulitis Differentil Dignosis Vlue of Imging Epiploic Appendgitis Differentil Dignosis 3717 R. Forstner, MD, A. Schneider, MD PD, Deprtment of Rdiology, Lndeskliniken Slzurg, Prcelsus Privte Medicl University, Müllner Huptstrsse 48, 5020 Slzurg, Austri Vlue of Imging Crohn Disese Differentil Dignosis Vlue of Imging Rectus Sheth Hemtom Differentil Dignosis Vlue of Imging Introduction References 375 One of the most chllenging prolems in clinicl routine is discerning the cuse of pelvic pin. From prcticl point of view, it seems useful to clssify pelvic pin s cute or chronic, ecuse these presenttions differ in their differentil dignoses nd therefore different imging strtegies for their evlution my e pproprite. Pelvic pin tht hs een present for 6 months or longer is defined s chronic pelvic pin. The differentil dignosis of lower dominl nd pelvic pin is long, nd encompsses gynecologicl, pregnncy-relted, gstrointestinl, urologicl, neurologicl, nd dominl wll cuses. Furthermore, psychologicl fctors hve een ttriuted to ply n importnt role in women suffering especilly from chronic pelvic pin. The single most importnt lortory test in ssessing pelvic pin in womn of reproductive ge is pregnncy test, ecuse ectopic pregnncy should e ruled out in ny women in this ge group presenting with the symptoms of dominl pin. The top dignoses of gynecologicl emergencies ccount for the vst mjority of referrls nd include ectopic pregnncy, corpus luteum cyst rupture, nd pelvic infection. Appendicitis ccounts for most of nongynecologicl emergencies.

2 356 R. Forstner nd A. Schneider Sonogrphy plys pivotl role s the primry imging modlity in gynecologic disorders cusing pelvic pin. CT nd MRI llow complementry ssessment of the pelvis nd domen including the gstrointestinl nd urologic system. In this chpter, common gynecologicl nd nongynecologicl cuses of cute nd chronic pelvic pin will e covered. Their reltive frequency of imging y MRI or CT is listed in Tle Gynecologic disorders highly ssocited with chronic pelvic pin such s endometriosis uterine firoids nd denomyosis re discussed in previous chpters in this ook. Tle Reltive frequency of imging for pelvic pin in clinicl routine Gynecologicl pthologies Frequency Nongynecologicl pthologies PID + Pelvic congestion + syndrome Tuoovrin ++ Appendicitis +++ scess Hydropyoslpinx ++ Diverticulitis +++ Ovrin torsion + Appendgitis + epiploic Ovrin vein + Crohn disese ++ thromosis Endometriosis ++ Rectus sheth + hemtom Uterine firoids ++ Frequency +, Low frequency; ++, medium frequency; +++, high frequency. Pelvic inflmmtory disese (PID) refers to n cute infection of the upper genitl trct in women in the reproductive ge, involving the uterus, fllopin tues, nd ovries. Per definition, PID should e distinguished from pelvic infections cused y medicl procedures, pregnncy, nd other primry dominl processes. PID usully results from sexully trnsmitted scending infections typiclly y Neisseri gonorrhoee or Chlmydi trchomtis, lthough 30% 40% of cses re polymicroil. Actinomyces nd tuerculosis ccount for rre cuses of PID nd my cuse tuoovrin scesses [1]. If PID is untreted or incompletely treted, there is sixfold risk of ectopic pregnncy. Twenty percent of the ptients my complin out pelvic pin, nd infertility is seen in 25% 60% of women with more thn one series of PID [2]. Occsionlly ptients with PID my develop Fritz-Hugh-Curtis syndrome due to peritonitis of the right upper qudrnt surfces nd the of right loe of the liver cused y cteril spred long the prcolic gutters [3] Imging findings in erly PID re typiclly sutle nd their interprettion is sed on the clinicl findings. Findings on CT nd MRI my include mild pelvic edem tht results in thickening of the uteroscrl ligments nd hziness of the pelvic ft. Contrst enhncement nd thickening of the fllopin tue my e signs of slpingitis. Enlrged nd normlly enhncing ovries, which my demonstrte polycystic ppernce, lso present inflmmtory chnges (Fig. 17.1). Periovrin strnding nd enhncement of the djcent peritoneum re common ssocited findings. In cses of endometritis, n norml endometril enhncement nd fluid within the endocervicl cnl, which displys similr imging chrcteristics s fluid in the cul-de-sc, my e oserved. (Fig. 17.1) The uterine cervix my e enlrged with n normlly enhncing endocervicl cnl in cses with ssocited cervicitis. Especilly the uterine chnges re etter ssessed on MRI thn on CT [3] Gynecologicl Cuses of Pelvic Pin Pelvic Inflmmtory Disese Hydropyoslpinx Slpingitis is the most importnt cuse for olitertion of the fimrited end of the tue, which leds to hydroslpinx. Other etiologies include fllopin tue tumors, endometriosis, nd dhesions from prior surgery. Serous fluid, lood, or pus my ccumulte nd cuse distension of the fllopin tue Dilted fllopin tues pper s fluid-filled tuulr structures rising from the uterine fundus, seprted from the ipsilterl ovry. The typicl finding is tuulr tortuous cystic structure with interdigitting murl sept (Fig. 17.2) These sept re thin nd disply low

3 Acute nd Chronic Pelvic Pin Disorders 357 Fig CT findings in PID in 29-yer-old womn. Hziness nd welike ftty infiltrtion of pelvic ft (rrow), free fluid (A), mrked swelling of the left ovry, nd mild dilttion of the uterine cvity (U) re demonstrted in infection y Chlmydi trchomtis. The ovries (*) re difficult to discriminte from scites due to their polycystic ppernce in oophoritis Fig. 17.2,. Hydroslpinx in CT nd MRI. Trnsxil CT () nd coronl T2WI (). A multiseptte lesion (rrows) in the left dnexl region is demonstrted in CT () nd MRI (): Its tuulr structure with widening t the cephld end is demonstrted on MRI (). The thin incomplete, interdigitting sept (smll rrows) re typicl finding of dilted fllopin tue in CT nd MRI signl intensity on T2-weighted imges. Distinct septl enhncement on contrst-enhnced T1WI or CT my support the dignosis of pyoslpinx (Fig. 17.3) [4]. The nture of fluid within dilted slpinx cn e est evluted y MRI. The signl intensity on the T1 nd T2WI vries in ccordnce with the contents, which rnges from wter-like fluid to proteinceous or hemorrhgic components. Multiplnr imging nd owel opcifiction fcilittes depiction of the tul origin nd differentition from dilted owel loops.

4 358 R. Forstner nd A. Schneider Fig Pyoslpinx in CT. A pedunculted cystic lesion (rrow) is identified djcent to the retroflected uterus. It extends from the left dnexl region posteriorly nd displces the opcified rectum (R). The distinct wll enhncement is indictive of pyoslpinx Differentil dignosis Pyoslpinx cn often not e relily differentited from hydroslpinx. As dimeters up to 10 cm re not uncommon, hydroslpinx my mimic multiloculted ovrin tumors, especilly cystdenoms. Identifiction of the ovry seprte from the lesion nd multiplnr imging ids in differentition. Any enhncing component within dilted tue should suggest the possiility of fllopin tue crcinom or ectopic pregnncy [5] Tuoovrin Ascess In the mjority of cses, tuoovrin scesses (TOA) result from pelvic inflmmtory disese. It is reported to complicte PID in up to one-third of ptients hospitlized for tretment [6]. Other etiologies include complictions of surgery or intr-dominl inflmmtory owel diseses, such s ppendicitis, diverticulitis, or Crohn disese. In most cses, TOA is cused y polymicroil infection with high prevlence of neroes. IUD users, especilly in the first few months fter insertion, re lso under higher risk of PID. Pelvic ctinomycosis is considered to e highly ssocited with the use of IUD [1]. TOA most commonly occurs in women in the reproductive ges. Tuoovrin scesses in postmenopusl women re rre, nd encountered in ptients with dietes or previous rdition therpy [7]. Becuse of the significnt ssocition with mlignncies in postmenopusl women presenting with TOAs, concomitnt pelvic mlignncy should e excluded [8]. The pthwy of the inflmmtory disese includes direct extension long the fllopin tues. A hemtogenous or lymphtic spred is found in the rre tuerculous involvement of the genitl trct [1]. The vst mjority of tuoovrin scesses re multiloculr msses with thick wlls nd necrotic res. Bowel, uterus, prietl peritoneum, nd omentum usully ecome dherent. The scess my enlrge nd fill the cul-de-sc or lek nd produce metsttic scesses nd cuse locl peritonitis In CT nd MRI, tuoovrin scesses re thick-wlled, complex heterogenous fluid-contining dnexl msses tht re found unilterlly or ilterlly (Fig. 17.4) They my contin irregulr inner contours, internl sept, gs, fluid, or fluid-deris level [3]. Necrosis or loculted liquid res my resemle serous fluid, ut lso e proteinceous or hemorrhgic with T1 short-

5 Acute nd Chronic Pelvic Pin Disorders 359 ening. On T2WI, tuoovrin scesses disply most commonly heterogeneously hyperintense signl on T2-weighted imges [2]. They re surrounded y thick, well-enhncing outer orders. Becuse of dense pelvic dhesions or firosis, mesh-like strnds in the pelvic ft plnes re lmost lwys found nd re well enhnced on CT or contrst-enhnced T1WI, nd disply low signl on T2WI. Involvement of djcent structures includes thickening of owel loops nd/or dilttion due to prlysis. Peritonel enhncement, especilly in the lesser pelvis, nd smll mounts of scites re signs of ssocited peritonitis (Fig. 17.5). Ostruction of the ureters my lso e oserved. Internl gs ules re the most specific rdiologic sign of n scess ut re unusul in tuoovrin scesses [9]. In cses of tuerculous TOAs, lrge mounts of scites hve een descried [1] Differentil dignosis Endometrioms my sometimes disply similr imging chrcteristics with thick rim; however, the clinicl ckground is different. Ovrin cncer nd especilly metstses often present lso s multiseptte ovrin msses. In ovrin cncers, well-enhnced sept nd solid intrlesionl compo- Fig. 17.4,. Bilterl tuoovrin scesses. Consecutive trnsxil FS T1WI (, ) t the level of the cetulum. Bilterl centrlly cystic thick-wlled dnexl lesions (*) show ill-defined mrgins towrd the surrounding ft. Excessive contrst enhncement long the uteroscrl ligments, rectl wll, mesorectl ft tissue nd the left round ligment (rrow) is lso noted (). R, rectum. Courtesy of Dr A. Heuck, Munich Fig. 17.5,. Peritonitis in tuoovrin scess. Trnsxil CT sns in the mid pelvis (, ). A left-sided tuoovrin scess is locted djcent to the pelvic sidewll (rrow) etween internl nd externl ilic vessels (). It presents s cystic peripherlly enhncing lesion with fluid fluid level (rrowhed) presenting deris (). Associted findings include scites, liner peritonel enhncement (smll rrows), nd netlike involvement of the pelvic ft nd the omentum (rrow) ()

6 360 R. Forstner nd A. Schneider nents re typiclly found. Signs of inflmmtion of the pelvic ft re missing in ovrin cncers. Furthermore, ovrin cncer is usully not ssocited with tul dilttion. However, in postmenopusl women with TOA, mlignncy is specil concern [8]. If tuoovrin scesses involve djcent pelvic orgns, the site of origin often cnnot e relily defined (Fig. 17.6). Tuerculous peritonitis involving the dnex mimics peritonel crcinomtosis with nodulrities long tuoovrin surfces, nd lrge mounts of scites [1] Vlue of Imging The dignosis of PID is sed on lortory studies, ssessment of vginl secretions in comintion with the clinicl exmintion, nd sonogrphic findings. In cse of nonspecific findings or suspected complictions of PID, especilly tuoovrin scess or peritonitis, CT or MRI serve s djunct imging modlities. CT is commonly used to ssess complictions of PID, especilly when tuoovrin scess or peritonitis is suspected. Furthermore, it ids in defining the origin of the tuoovrin scess nd differentites it from inflmmtory owel disese. It is lso especilly useful s guidnce for surgery or CT dringe. MRI nd CT re oth useful in differentition etween n dnexl tumor nd n scess. The imging findings, however, cn only e interpreted in context with the clinicl ckground. MRI is more useful thn CT in differentiting hydroslpinx from cystic ovrin tumor Ovrin Torsion Ovrin torsion is most commonly ssocited with tul torsion. Two ge groups tend to e ffected: children nd women in their first three decdes, nd postmenopusl women. c Fig c. Ascess involving ovries nd sigmoid colon. Three consecutive CT scns ( c) in nd ove the cetulr level in 36-yer-old womn with pelvic pin nd leukocytosis. A multiseptte cystic lesion (rrow) with perilesionl ft strnding is identified lterl of the uterus (, ) involving the left dnex nd sigmoid colon. The tiny spot of free ir (smll rrow) is highly specific of the inflmmtory nture of this process ()

7 Acute nd Chronic Pelvic Pin Disorders 361 Fig. 17.7,. Twisted ovrin dermoid. Coronl () nd trnsxil T2WI (). A lrge lesion with fluid ft level () nd Rokitnsky nodule (*) typicl for dermoid is seen in the right middomen. Twisting (rrow) of the thickened pedicle, which leds from the uterus to the lesion, is seen on the coronl plne (). The ovrin origin of the lesion cn e identified ecuse of the smll peripherl ovrin follicles (smll rrows) ().Courtesy of Dr. K. Kinkel, Genev Ovrin torsion is cused y prtil or complete rottion of the ovrin vsculr pedicle. While venous flow is initilly compromised, cusing swelling nd edem, rteril flow usully mintins until lte in the course, which is ttriuted to the dul lood supply of the ovry [10]. Finlly, hemorrhgic infrction leds to irreversile loss of the ovry. Predisposing fctors for ovrin torsion include n underlying unilterl ovrin tumor (50% 60%), most likely dermoids (Fig. 17.7), nd cystic ovrin lesions including prtul cysts. Lesion size of more thn 6 cm seems higher risk for torsion [11]. Especilly in children, torsion my lso e encountered in norml-sized ovries [12]. Furthermore, hypermoile dnex or elongted fllopin tues nd incresed dominl pressure hve een reported to e responsile for ovrin torsion. Women in their first three decdes hve the highest incidence of ovrin torsion, which is relted to the higher frequency of physiologicl cysts nd enign cystic tumors, infertility therpy, nd pregnncy. Approximtely 20% of torsions occur during pregnncy, typiclly during the first nd second trimesters. In postmenopusl women, torsion typiclly ffects enign dnexl tumor, most commonly serous cystdenoms, wheres mlignnt tumors tend not to undergo torsion [13]. Mssive edem of the ovry is rre disorder found in the second nd third decdes of life nd considered vrint of ovrin torsion. It results from prtil or intermittent torsion nd is chrcterized y n excessively enlrged edemtous ovry [10]. The right ovry is more likely to twist thn the left, suggesting tht the sigmoid colon my help to prevent torsion The finding of cystic ovrin tumor, especilly dermoid cyst in young women who present with cute pin nd vomiting is highly suspicious of dnexl torsion. The imging findings depend on the degree nd durtion of torsion. Thickening of the fllopin tue with hemorrhge is suggestive of torsion, especilly when ssocited with n dnexl cystic mss. Torsed dnexl msses re often locted midline, crnil to the uterine fundus. A twisted edemtous pedicle cn e oserved rising from the lesion to the uterus with mixed signl intensity on ll sequences on MRI (Fig. 17.7) [14]. Sometimes when trcking down the ovrin vsculr pedicle, coiled vsculr pedicle my produce the whirl pool sign [15]. In prepuertl

8 362 R. Forstner nd A. Schneider nd puertl girls where torsion of norml ovry occurs in 50%, unilterl solid mss with peripherl smll cysts is indictive of torsed ovry (Fig. 17.8). In cse of hemorrhgic infrction, the enlrged ovry my show low signl intensity on T2WI due to interstitil hemorrhge, nd no wll enhncement of the displced follicles is oserved [14]. In dults, most commonly mss with hyperintense signl on T1 nd T2 due to hemorrhge hs een descried [16]. Smooth wll thickening of the twisted dnexl cystic mss nd thin hyperintense rim t the periphery of the lesion on T1-weighted imges re further signs in ovrin torsion. A tuulr or comm-like structure prtilly covering the ovry represents the fllopin tue nd my lso disply hemorrhgic contents. CT studies hve reported dimeter of the fllopin tue of 2 4 cm [17]. Contrst enhncement on CT nd MRI depends on the degree of vitlity [16]. MR findings in hemorrhgic infrction include lck of enhncement, engorged vessels surrounding the lesion nd signl intensity of hemtom with high SI on T1 nd T2 WI [18]. Nonspecific findings include devition of the uterus to the twisted side, scites, nd olitertion of pelvic ft Differentil dignosis Cliniclly, ruptured ovrin cysts my resemle ovrin torsion. In ptient with cute pelvic pin, hemorrhgic lesion within norml size ovry is typiclly ruptured ovrin cyst. Furthermore, unlike in most cses of ovrin torsion, clotted lood my e detected in the lesser pelvis. Wll edem of n dnexl mss, engorged dnexl vessels or dilttion of the fllopin tue re missing. Tuoovrin scess nd hydroslpinx my resemle dvnced dnexl torsion. Lck of enhncement supports the dignosis of ovrin torsion. In children, sonogrphy usully llows the dignosis of ppendicitis s cuse of cute pelvic pin. In cse of suspected scess or n ovrin mss, MRI my id in further ssessment of the dnex. Rrely, clcified mss my result from chronic infrction which cnnot relily e differentited from clcified ovrin tumor [19] Dignostic Vlue Erly dignosis is crucil to prevent irreversile ovrin dmge nd prevent infectious complictions. Fig Torsion of norml ovry. Trnsxil T2WI t umilicl level. In 14-yerold girl with excessive intermittent pelvic pin for severl dys, sonogrphy detected n indeterminte solid right dnexl mss. MRI shows predominntly low-signlintensity mss with numerous smll peripherl cysts (smll rrows), representing displced follicles. Norml left ovry(*) At surgery, the right ovry hd undergone complete hemorrhgic infrction. Courtesy of Dr. K. Kinkel, Genev

9 Acute nd Chronic Pelvic Pin Disorders 363 Fig. 17.9,. Hemtoslpinx in ectopic tul pregnncy. Trnsxil T2WI () nd contrst-enhnced T1WI with ft sturtion (FS) (). In 27-yer-old womn with positive pregnncy test, cystic dnexl mss (*) displces the uterus, which displys widening of the endometril cvity. The dnexl lesion is seprted from the djcent left ovry (rrow) nd displys inhomogenous signl intensity with res of high nd low SI on T2WI () indictive of hemorrhge. The cystic contents of the fllopin tue nd distinct homogenous tul wll enhncement is demonstrted following contrst medi dministrtion (). Courtesy of Dr. T.M. Cunh, Lison This is why in most cses ptients with suspected torsion on sonogrphy will immeditely undergo surgicl untwisting. MRI nd CT re often used in cliniclly not so typicl cses, especilly in chronic torsion. Prticulrly in erly torsion, the imging signs my e indictive ut not specific of ovrin torsion. MRI nd CT re prticulrly useful in detecting twisted lesions displced outside the pelvis, where sonogrphy my e limited. In pregnncy nd in children, MRI is the modlity of choice to further ssess suspected ovrin torsion Ectopic Pregnncy Ectopic pregnncy descries implnttion nd growth of the fertilized ovum t ny site other thn the endometril cvity. The fllopin tue ccounts for the vst mjority of ll ectopic gesttions (95%), with 75% found in the mpull nd the reminder out eqully occurring in the fimril nd isthmic portions [20]. Rrely, ectopic pregnncy my occur within the ovry (3.2%), or within the peritonel cvity (1.3%). Ectopic cervicl pregnncy is more commonly found in pregnncies chieved through in-vitro fertiliztion technologies [21]. The mjor cuse of ectopic pregnncy is disruption of norml tul ptency due to infection, surgery, müllerin nomlies, or tumors. The rise of ectopic pregnncies within the lst decdes is highly ssocited with the incresed incidence of pelvic inflmmtory disese. A history of PID with chronic slpingitis is found in 35% 50% of ptients with ectopic pregnncy Tul wll enhncement nd fresh tul hemtom re descried s specific findings for ectopic tul pregnncy [22] (Fig. 17.9). The gesttionl sc is cystic, centrlly fluid-filled structure tht is surrounded y thick-wlled peripherl rim. The ltter displys inhomogeneous signl intensity on T2WI nd medium signl intensity on T1WI, which my contin smll res of high signl intensity suggestive of lood [23]. When such gesttionl sc-like structure is found seprted from the uterus without tul structures, this finding is equivocl, due to the differentil dignostic prolems of cystic ovrin msses [22]. Identifiction of the uterine junctionl zone etween the gesttionl sc surrounded y myometrium nd the uterine cvity is highly suggestive of rre type of ectopic pregnncy, interstitil pregnncy [24]. In suspected ectopic pregnncy, the comintion of n dnexl mss nd intrperitonel hemorrhge is suggestive of tul rupture.

10 364 R. Forstner nd A. Schneider Differentil Dignosis In women of reproductive ge presenting with elevted humn chorionic gondotropin levels, demonstrtion of gesttionl sc-like structure is highly suggestive of ectopic pregnncy. However, ovrin cncer my rrely e detected during erly pregnncy nd e misdignosed s ectopic pregnncy [25]. Bsed on the MRI findings lone, ectopic pregnncy my e misdignosed s n ovrin mss, e.g., ovrin cncer or endometriosis. Interstitil ectopic pregnncy my resemle cystic denomyoms or necrotic firoids [24] Vlue of imging The dignosis of ectopic pregnncy is usully estlished y the comintion of et hcg levels nd trnsvginl sonogrphy. The role of MRI hs not een defined. It my, however, provide dditionl informtion in cse of unequivocl sonogrphy, especilly to etter determine the exct site of origin of ectopic pregnncy [24] Nongynecologicl Cuses of Pelvic Pin Pelvic Congestion Syndrome Pelvic congestion syndrome or pelvic venous incompetence is common cuse of chronic noncyclicl pelvic pin tht ffects most often multiprous women of reproductive ge. The symptoms of chronic dull pelvic pin, pressure, nd heviness hve een ttriuted to dilted, tortuous, nd congested veins tht re produced y retrogrde flow through incompetent vlves in ovrin veins. Ptients with pelvic congestion syndrome my lso suffer from dyspreuni (71%), dysmenorrhe (66%), nd postcoitl che (65%) [26]. The prevlence of pelvic congestion syndrome is closely relted to the frequency of ovrin vrices, which occur in 10% of the generl popultion of women. Within this group of ptients, up to 60% my develop pelvic congestion syndrome [27]. The pthogenesis of pelvic congestion syndrome is most likely multifctoril nd influenced y hormonl effects, multiprity, nd previous surgeries. Pelvic congestion syndrome my lso result from ostructing ntomic nomlies such s retroortic left renl vein or right common ilic vein compression [26]. It my lso e ssocited with symptomtic hemturi in the nutcrcker phenomenon, which is cused y left ovrin vein congestion secondry to compression of the left renl vein y the superior mesenteric rtery [28]. Dilted veins involved include veins in the rod ligments, ovrin plexus, in the pelvic sidewlls. Vrices within the prvginl plexus, vulv, or the lower extremities my lso e found [28]. Polycystic chnges in ovries re ssocited in pproximtely 40% of cses [29] The typicl imging findings re dilted nd tortuous vsculr structures engorging the uterus nd ovries, which my extend to the pelvic sidewlls or communicte with prvginl veins. CT s well s MR imging re noninvsive methods used to dignose pelvic vrices. The dignosis of pelvic vricosities in CT is estlished y the demonstrtion of t lest four ipsilterl dilted pruterine veins of vrying clier, with width of t lest one vein lrger thn 4 mm or dimeter of the ovrin vein of more thn 8 mm (Fig ) [30]. On T1-weighted MR imges, pelvic vrices disply low signl intensity ecuse of flow-void rtifcts. On T2WI, the signl intensity depends on the velocity of lood flow. Contrstenhnced MRA displys enhncing veins with mximl opcifiction in venous phse. On grdientecho MR imges, the vrices typiclly disply high signl intensities Differentil Dignosis Incompetent nd dilted ovrin veins re frequently seen on CT in symptomtic prous women (Fig ) [31]. Congenitl or cquired vsculr mlformtions of the uterus or prmetri present lso s vsculr lesions. Contrst-enhnced CT or MRI my id in the differentition y the erly enhncement of rteriovenous mlformtions in contrst to more delyed enhncement in vricosities [32]. Adnexl msses with torsion or rre uterine tumors, especilly choriocrcinoms my lso e surrounded y thick, tortuous, well-enhnced vessels. The clinicl ckground nd imging findings of n dnexl or uterine mss id in the differentil dignosis.

11 Acute nd Chronic Pelvic Pin Disorders 365 Fig c. Pelvic congestion syndrome. Trnsxil CT t the level of the cervix uteri () nd coronl scns in the pelvis nd retroperitoneum (, c). Multiple dilted tortuous pelvic vsculr structures re demonstrted within the prmetri nd pelvic sidewlls (). The coronl imges demonstrte engulfment of the uterus (U) y these vsculr structures (, c). Dilttion of oth ovrin veins (rrows), which disply dimeter of more thn 8 mm, is shown in c. U, uterine corpus, C, cervix c Vlue of Imging The dignosis of ovrin nd pelvic vrices is estlished y sonogrphy. CT or MRI re used to confirm the dignosis nd to id in therpy guidnce. However, these cross-sectionl imging techniques, which re not performed in n upright position my underestimte the venous pthology. Severl tretment options for pelvic congestion syndrome, including lproscopic trnsperitonel ligtion of ovrin veins re currently under investigtion. Percutneous coil emoliztion of the gondl vein seems to e sfe technique tht relieves pelvic pin in mny ptients with pelvic congestion syndrome [27] Ovrin Vein Thromosis Ovrin vein thromosis typiclly presents compliction in the postprtum period nd is encountered most frequently fter cesren section. It is cused y venous stsis nd hypercogulility. The incidence of puerperl vein thromosis (POVT) is pproximtely 1 in 2,000 deliveries [33]. Other conditions such s infection, recent surgery, mlignncy, nd Crohn disese increse the risk for ovrin vein thromosis [34]. Although rre entity, ovrin vein thromosis presents differentil dignostic prolem ecuse of the unspecific clinicl symptoms, including fever, nd the potentil of ftl complictions due to uterine necrosis

12 366 R. Forstner nd A. Schneider Fig Pelvic vrices in n symptomtic womn. CT shows numerous dilted pruterine veins of vrying dimeter in n symptomtic 37-yer-old multiprous womn. U, uterus. R, rectum or septic emoli [35]. As the mjority (80% 90%) of ovrin vein thromoses occur in the right ovrin vein, right-sided pin is typicl clinicl presenttion Ovrin vein thromosis is usully well depicted s dilted tuulr structure extending from the dnex to the pr-ortl region ner the renl hilum. Contrst-enhnced CT llows direct visuliztion of the low ttenuting centrl thromus surrounded y vsculr contrst-enhncement (Fig ) [36]. In MRI, the thromus my disply high SI on T1 nd T2WI. Trnsxil grdient-echo imges or contrstenhnced T1WI imges id in differentition of flow rtifcts from thromosis. Imging in the coronl plne demonstrtes the full extent of ovrin vein involvement Differentil dignosis The differentil dignosis includes other cuses of right-sided pelvic pin such s ppendicitis, dnexl torsion, pelvic scess, pyelonephritis, nd endometritis [37] Vlue of Imging Color Doppler ultrsound is the primry imging modlity in ptients with suspected ovrin vein thromosis. Especilly in the postprtl period, its performnce is often limited due to uterine enlrgement, postopertive chnges, or oesity. This is why CT or MRI re commonly performed to rule out ovrin vein thromosis Appendicitis Appendicitis ffects ll ge groups; it peks in the erly twenties nd then grdully declines towrd the senium. Appendicitis is found 1.4 times more frequently in men thn in women. In the mjority of cses, ppendicitis results s development from ostruction of the lumen y fecliths, lymphoid follicle hyperplsi, foreign odies, nd tumors. Vritions in the ppendicel loction mke the clinicl

13 Acute nd Chronic Pelvic Pin Disorders 367 ssessment of ppendicitis difficult. The position of the ppendix is retroperitonel in out 30% of cses. Intrperitonel loction includes retrocecl, retroilel, deep pelvic, nd rrely right upper qudrnt loction. Acute ppendicitis is the most common cuse of emergency dominl surgery. Since clinicl dignosis is difficult, ppendectomy fter flse-positive dignosis of ppendicitis is still performed in up to 20% of cses [38]. In women of fertile ge, the error rte reches up to 40%, ecuse cute gynecologicl processes tend to cliniclly simulte cute ppendicitis [39]. Ptients with ppendicitis hve significntly shorter durtion of pin thn ptients with other disorders. Perfortion nd scess formtion complicted ppendicitis in 38% 55%, with the highest rtes occurring in children nd in elderly ptients On CT the norml ppendix ppers s tuulr structure with dimeter of less thn 6 mm tht often contins ir or contrst medi. CT findings of cute ppendicitis include enlrgement of the ppendix (>6 mm in outer dimeter), enhncement of the thickened ppendicel wll, nd ft strnding of the perippendicel region (Fig ) [40]. Signs indictive of perfortion include extrluminl ir, extrluminl ppendicolith, defect in the enhncing ppendicel wll, nd n scess or phlegmon [41]. A phlegmon is chrcterized y diffuse inflmmtion of the perippendicel ft with no or smll, ill-defined fluid collections. An scess is well-delineted fluid collection with rim enhncement [41]. Focl thickening of Fig ,. ovrin vein thromosis. CT scns t the level elow the renl hilum () nd lower lumr region (). In ptient with ony metstsizing rest cncer (m), nonoccluding thromus (rrow) is identified within the dilted right ovrin vein (). At the level just elow the renl hilum, the renl vein (rrowhed) is ptent ()

14 368 R. Forstner nd A. Schneider Fig ,. CT findings in cute ppendicitis. Trnsxil scns in right lower qudrnt (, ). The tuulr enhncing structure with dimeter of 9 mm represents the dilted ppendix (rrow). It is surrounded y mrked ft strnding of the pericecl ft nd djcent fcil thickening.. At the se of the ppendix (rrow), thickening of the cecum cn e oserved, which presents the rrowhed sign (). A smll fluid collection is seen long the surfce of the psos muscle () the cecum due to the inflmmtory process cn e oserved nd hs een descried s the rrowhed sign [40]. MR criteri suggesting cute ppendicitis do not differ from those s descried in CT. They include thickening of the ppendicel wll, dilted fluid-filled lumen, nd incresed intensity of perippendicel tissue on T2-weighted imging or contrst-enhnced imges (Fig ) [42]. Extrintestinl fluid-filled hyperintense lesions with wlls tht re hypointense on T2-weighted imges nd thick on the contrst-enhnced imges re indictive of scesses. Demonstrtion of ir within such lesion on MRI or CT llows the definite dignosis of n scess [43] Vlue of Imging In children nd women of childering ge, sonogrphy is the primry imging modlity to ssess ptient with suspected cute ppendicitis. However, due to its inility to visulize the norml ppendix, nd due to vritions in loction, CT is wrrnted in negtive US study [38]. It is regrded s the imging modlity of choice in the dignosis of ppendicitis, with excellent performnce (sensitivity nd specificity rtes of 90% 95% nd 95% 100%, respectively). Due to its lck of ioniztion, MR is n lterntive, highly useful imging tool in the ssessment of cute

15 Acute nd Chronic Pelvic Pin Disorders 369 Fig ,. Appendicitis in MRI. Trnsxil () nd sgittl T2WI (). A tuulr fingerlike lesion (rrow), chrcteristic of the dilted fluid-filled ppendix is seen in the right lower qudrnt. The low-signl-intensity structure t the se of the ppendix seen in the sgittl plne () presents n ppendicolith (*). Appendicoliths re highly specific sign of ppendicitis; however, they re found in only 12% of cses. Courtesy of Dr. M. Umschden, Wolfserg right-lower-qudrnt pin, especilly in children nd pregnnt women [44, 45] Diverticulitis Colonic diverticulosis is very common condition in Western society, ffecting 5% 10% of the popultion over 45 yers, nd 80% over 85 yers of ge [46]. Diverticul re smll sccultions of mucos nd sumucos through the musculris of the colonic wll. They develop where the nerve nd lood vessel penetrte the musculris etween the tenie coli nd mesentery [47]. The most common loction for diverticul is the sigmoid colon. Acute diverticulitis occurs when the neck of diverticulum is occluded y food prticles, stool, or inflmmtion, resulting in microperfortion of the diverticulum nd surrounding mild pericolic inflmmtion, which is usully contined y pericolonic ft nd mesentery. This my led to loclized scess or, if djcent orgns re involved, fistul. Poor continment results in free perfortion nd peritonitis [48]. The leding clinicl symptom is left-lower-qudrnt pin nd tenderness, which is often present for severl dys efore dmission. Lowgrde fever nd mild leukocytosis re common ut their sence does not exclude diverticulitis. Right-sided diverticulitis occurs in only 1.5% of ptients in Western countries ut is more common in Asins nd tends to ffect younger ptients (Fig ) [49]. Diverticulitis of smll intestine or trnsverse colon is rre [50] At CT, diverticulosis ppers s smll, ir-filled outpouchings of the colonic wll, most commonly in the sigmoid colon. In MRI on T1WI diverticul pper s hypointense ginst the high-signl-intense pericolonic ft. The most common imging finding in diverticulitis is prcolic ft strnding, which is chrcteristiclly more severe thn the focl colonic wll thickening (Fig ) The key to distinguishing diverticulitis from other inflmmtory conditions ffecting the colon is the presence of diverticul in the involved segment [50]. Contrst-enhnced CT or ftsuppressed T1-weighted imge contrst provides the est ssessment of thickening of the colonic wll nd the pericolonic ft strnding. Other common imging findings re thickening of the lterl conl fsci nd smll mounts of scites in the cul-de-sc. Accumultion of fluid in the root of the sigmoid mesentery is clled the comm sign nd engorgement of the mesenteric vessels is clled the centipede sign [51].

16 370 R. Forstner nd A. Schneider Fig ,. Right-sided diverticulitis. Trnsxil CT scns t the level of the pelvic crest t the initil presenttion () nd fter 3 weeks (). In 33-yer-old womn who presented with cute right qudrnt pin nd lortory signs of inflmmtion, diffuse inflmmtory process (rrow) in the pericecl region is demonstrted. It ws dignosed s cute retrocecl ppendicitis (). At surgery, there ws no evidence of inflmmtory chnges of the ppendix. The follow-up 3 weeks lter demonstrted complete resolution of the inflmmtory rection nd reveled severl diverticul (rrow) of the cecum () Fig Sigmoid diverticulitis. Multiple ircontining diverticul re found long the sigmoid colon. In this ptient with cute pelvic pin, focl wll thickening, stenosis, nd prcolic ft strnding (rrow) re signs of cute diverticulitis involving the distl sigmoid colon. R, rectum

17 Acute nd Chronic Pelvic Pin Disorders 371 Complictions of diverticulitis include diverticulr scess, colovesicl fistul, nd perfortion. An scess tht occurs in up to 30% of cses ppers s hypodense fluid collection with contrst-enhncing rim nd surrounding inflmmtory chnges. It my contin ir or ir fluid levels [47]. A colovesicl fistul is suspected when ir is seen in the ldder nd there is thickening of the ldder wll djcent to disesed segment of owel [52]. Another compliction of diverticulitis cn e focl contined perfortions. They pper s smll extrluminl deposits of ir or extrvstion of orl contrst mteril. Pneumoperitoneum is rre finding in ptients with diverticulitis [47] Differentil Dignosis The most importnt differentil dignosis is colon crcinom. The presence of pericolic lymph nodes suggests the dignosis of colon cncer rther thn diverticulitis [53]. The length of the involved segment (>10 cm), engorgement of djcent sigmoid mesenteric vsculture, nd the presence of fluid in the root of the sigmoid mesentery fvors the dignosis of diverticulitis [47, 54]. However, in some cses it my not e possile to distinguish diverticulitis from colon cncer nd concomitnt diseses my e found in 3% 18% [54] Vlue of Imging The role of imging in diverticulitis is to rule out complictions of diverticulitis nd the necessity for emergent surgery. If n scess is detected CT guided percutneous dringe my e perfumed. MR imging cn e useful in the dignosis of right sided diverticulitis in young or pregnnt ptients with suspected ppendicitis Epiploic Appendgitis Appendices epiploice re pedunculted ft filled structures protruding from the externl surfce of the colon into the peritonel cvity. They vry considerly in size, shpe, nd contour. In oese persons nd people who hve recently lost weight, they re lrgest. The verge length is 3 cm, lthough they re occsionlly up to 15 cm in size [55]. They re presumed to serve protective cushion during peristlsis. Epiploic ppendgitis, lso known s hemorrhgic epiploitis or ppendicitis epiploic, is rre enign self-limiting pthology secondry to torsion or spontneous venous thromosis of drining vein. It occurs most commonly in the second to fifth decdes of life, with similr incidence mong men nd women [55]. Ptients most commonly present with sudden onset of dominl pin without leukocytosis nd fever [56] Norml ppendices epiploice re usully not seen on CT or MRI unless they re surrounded y sufficient mount of intrperitonel fluid such s scites or hemoperitoneum (Fig ). Imging findings of epiploic ppendgitis include n ovl-shped fingerlike prcolic mss with the ttenution of ft nd perippendicel ft strnding [57]. In CT, the density tends to e higher thn uninvolved ft. A well circumscried hyperttenuting rim tht surrounds the mss nd represents the inflmed viscerl peritonel lining is chrcteristic finding (Fig ). Adjcent colonic wll thickening nd compression my lso e seen [56]. Sometimes high ttenution centrl dot representing thromosed centrl vessels or centrl res of hemorrhge cn e seen [57]. Rrely, dystrophic clcifiction from previously infrcted ppendge my e evident [58] Differentil Dignosis Segmentl omentl infrction, which is often loclized on the right side of the omentum, occurs similrly to ppendgitis epiploic from torsion or spontneous venous thromosis. Imging findings rnge from sutle focl hzy soft-tissue infiltrtion of the omentum to tumor-like inflmmtory processes tht my or my not lie immeditely djcent to the colon [57, 58]. As fetures my lso overlp with those of ppendgitis epiploic, the term focl ft infrction hs een suggested y some uthors for oth entities [57].

18 372 R. Forstner nd A. Schneider Fig Norml ppendices epiploice in CT. Appendices epiploice of the sigmoid colon present pedunculted ft structures, which protrude from the sigmoid surfce into the peritonel cvity (rrow). They re esily visulized ecuse of scites in this womn with peritonel crcinomtosis. Smll sigmoid diverticul which present ircontining murl outpouchings into the perisigmoid ft tissue re lso demonstrted (rrowhed) Fig Appendgitis epiploic. In 29- yer-old ptient with cute pin, tender 2.5-cm soft-tissue infiltrtion (rrow) with djcent reticulr ftty infiltrtion t the umilicl level is demonstrted. Becuse of its well-circumscried hyperttenuting rim, it presents more likely ppendgitis epiploic thn omentl infrction. The lesion vnished within few dys of conservtive therpy Vlue of Imging Epiploic ppendgitis nd omentl infrction re cuses of cute pelvic pin tht re often misdignosed cliniclly s cute ppendicitis or diverticulitis. Bsed on the imging findings, especilly CT llows definite dignosis in most cses nd ptients cn e mnged conservtively Crohn Disese Crohn disese is chronic grnulomtous inflmmtory intestinl disese with men ge of presenttion in the third nd fourth decdes. It cn ffect ny prt of the gstrointestinl trct from the mouth to the nus, often involving multiple discontinuous sites. The smll intestine is involved in 80% of cses,

19 Acute nd Chronic Pelvic Pin Disorders 373 most commonly t the terminl ileum. The colon is ffected either with or without involvement of the smll intestine [59]. Leding clinicl mnifesttions re prolonged dirrhe with dominl pin, weight loss, nd fever. Becuse of trnsmurl inflmmtion, owel loops my dhere to ech other nd result in msses, fistuls, nd ostruction. The development of sinus trcts cn led to serous penetrtion nd owel wll perfortion. This compliction my e ssocited with n cute presenttion of loclized peritonitis with fever, dominl pin, nd tenderness. Perinl disese such s nl fissures, fistuls, nd scesses occur in 22% of ptients with Crohn disese, nd re often the first clinicl mnifesttion [60] Bowel wll thickening, usully rnging from 1 to 2 cm, is the most consistent feture of Crohn disese in CT nd MRI imges [61]. Prticulrly fter intrvenous dministrtion of contrst mteril, murl strtifiction (trget ppernce) is often seen in ctive lesions. An inflmed owel wll displys mrked enhncement fter intrvenous contrst medi, nd the intensity of enhncement correltes with the degree of inflmmtory lesion ctivity [62]. Luminl nrrowing, prestenotic dilttion, nd firoftty prolifertion of the mesentery, nd mesenteric lymph nodes rnging from 3 to 8 mm in size re further common findings (Fig ). In Fig ,. Crohn disese in CT. Smll owel loops with dilttion nd stenoses re demonstrted in two pelvic CT scns (, ). An ileum sling shows trnsmurl wll thickening nd intense contrst enhncement (rrow) (). Adjcent mesenteric hypervsculrity presents the com sign (long rrow) nd is nother sign of inflmmtory ctivity (). Heterogeneity of surrounding ft with incresed ttenution presents firoftty prolifertion (rrowhed) ()

20 374 R. Forstner nd A. Schneider CT, firoftty prolifertion shows slightly incresed ttenution. In MRI, the signl intensity is decresed compred with norml ft seprting the owel loops. Phlegmon nd scesses cn occur in the smll owel mesentery, dominl wll, or psos muscle or perinlly. They re well demonstrted on CT nd ft-sturted T1W MR imging [59]. Fistuls nd sinus trcts re lso depicted; however, the reported sensitivity of MR imging for depicting sinus trcts is 50% 75% compred to conventionl enteroclysis study [63] Differentil Dignosis Ulcertive colitis is mucosl disese tht primrily ffects the rectum. It is typiclly left-sided or diffuse, nd only rrely involves the right colon exclusively [64]. The men wll thickness in Crohn disese is usully greter thn in ulcertive colitis [65]. The hlo sign, low-ttenution ring in the owel wll cused y deposition of sumucosl ft, is seen more commonly in ulcertive colitis thn in Crohn disese. Prolifertion of mesenteric ft is lmost exclusively seen in Crohn disese, wheres prolifertion of perirectl ft is nonspecific nd cn result from Crohn disese, ulcertive colitis, pseudomemrnous colitis, or rdition colitis [64]. Ascesses re lmost exclusively found in Crohn disese nd not in ulcertive colitis [62] Vlue of Imging Cross-sectionl imging is le to demonstrte trnsmurl extent, skip lesions eyond severe luminl stenoses, nd intrperitonel extrintestinl complictions. However, CT nd MR imging re inferior compred to enteroclysis in the depiction of erly disese mnifesttions nd of fistuls nd sinus trcts [59] Rectus Sheth Hemtom Rectus sheth hemtom is n uncommon nd often misdignosed condition resulting from either rupture of the epigstric vessels or the rectus muscle itself. The hemtom my e cused y cogultion disorders, trum, or nticogultion therpy [65]. Cliniclly, most ptients present with cute dominl pin, peri- or infrumilicl mss, nd nemic syndrome. Some ptients lso hve history of severe coughing episodes due to ronchil infection The shpe of rectus sheth hemtoms depends on the reltionship to the rcute line, which is cm elow the umilicl level [66]. Aove this level, they usully pper s spindle-shped due to encsement y firm poneurotic sheths (Fig ). Below the rcute line, hemtoms tend to pper sphericl nd my communicte with extrperitonel pelvic nd perivsculr pelvic spces [66]. In CT, hemtoms present s homogeneous hyperdense lesions with thin circumferentil hlos of low density. Clot resorption leds to diminution of density nd fluid fluid levels ecuse hemtocrit effect my e found within hemtoms [67, 68]. Additionl findings of rectus sheth hemtom include incresed density of the djcent sucutneous ft nd enlrgement of the nterolterl muscles [66]. On MRI, rectus sheth hemtoms demonstrte heterogeneous signl intensities with res of high signl intensity on T1-weighted nd T2-weighted imges. Fluid fluid levels nd concentric ring sign cn lso e noted [69] Differentil Dignosis The cute clinicl onset in ptient under nticogultion supports the dignosis of rectus sheth hemtom. MR imging my e useful in differentition of chronic rectus sheth hemtoms from nterior dominl wll msses such s lipom, hemngiom, neurofirom, desmoid tumor, softtissue srcom, lymphom, or metsttic lesions. Although leeding into neoplsm my occur, hyperintense regions re rrely oserved in tumors [66] Vlue of Imging In the presence of cliniclly suspected rectus sheth hemtom or equivocl findings in sonogrphy, CT should e performed. CT usully llows the correct dignosis nd ovites unnecessry surgicl interventions [67].

21 Acute nd Chronic Pelvic Pin Disorders 375 Fig Rectus sheth hemtom in CT. At the umilicl level, spindle-shped lesion is seen in the left rectus muscle (rrow). It shows homogenous high density nd is surrounded t its nterior periphery y miniml hypodense rim. Only miniml thickening of the djcent lterl dominl muscles cn e noted References 1. Kim SH, Kim SH, Yng DM et l (2004) Unusul cuses of tuo-ovrin scess. CT nd MR imging findings. Rdiogrphics 24: Ghits AA (2004) The spectrum of pelvic inflmmtory disese. Eur Rdiol 14:E184 E Sm JW, Jcos JE, Birnum BA (2002) Spectrum of CT findings in cute pyogenic pelvic inflmmtory disese. Rdiogrphics 22: Tukev TA, Aronen HJ, Krjlinen PT et l (1999) MR imging in pelvic inflmmtory disese: comprison with lproscopy nd US. Rdiology 210: Kwkmi S, Togshi K, Kimur I et l (1993) Primry mlignnt tumor of the fllopin tue: ppernce t CT nd MR imging. Rdiology 196: Livengood CHH (2005) Tuoovrin scess. Cited 21 April Rodriguez-de Vlesques A, Yoder CI, Velsquez PA et l (1995) Imging effects of dietes on the genitourinry system. Rdiogrphics 15: Protopps AG, Dikomnolis ES, Milingos SD et l (2004) Tuo-ovrin scesses in postmenopusl women:gynecologicl mlignncy until proven otherwise? Eur J Ostet Gynecol Reprod Biol 15:114: Bennett GL, Slywotzky CM, Giovnniello G et l (2002) Gynecologic cuses of cute pelvic pin: spectrum of CT findings. Rdiogrphics 22: Lee EJ, Kwon HC, Joo HJ et l (1998) Dignosis of ovrin torsion with color Doppler sonogrphy: depiction of twisted vsculr pedicle. J Ultrsound Med 17: Sherrd GB, Hodson CA, Willims HJ et l (2003) Adnexl msses nd pregnncy: 12-yer experience. Am J Ostet Gynecol 189: Grif M, Itzch Y (1988) Sonogrphic evlution of ovrin torsion in childhood nd dolescence. AJR Am J Roentgenol 150: Koonings PP, Grimes DA (1989) Adnexl torsion in postmenopusl women. Ostet Gynecol 73: Hque TL, Togshi K, Koyshi H et l (2000) Adnexl torsion: MR findings of vile ovry. Eur Rdiol 10: Lee AR, Kim KHK, Lee BH, Chin SY(1993) Mssive edem of the ovry: imging findings. AJR Am J Roentgenol 161: Kimur I, Togshi K, Kwkmi S et l (1994) Ovrin torsion: CT nd MRI ppernces. Rdiology 190: Ghossin MA, Buy JN, Bzot M et l (1994) CT in dnexl torsion with emphsis on tul findings: correltion with US. J Comput Assist Tomogr 18: Rh SE, Byun JY, Jung SE et l (2003) CT nd MR imging fetures of dnexl torsion. Rdiogrphics 22: Currrino G, Rutledge JC (1989) Ovrin torsion nd mputtion resulting in prtilly clcified, pedunculted cystic mss. Peditr Rdiol 19: Bouyer J, Coste J, Fernndez H et l (2002) Sites of ectopic pregnncy: 10 yer popultion sed study of 1,800 cses. Humn Reprod 17: Ushkov FB, Elchll U, Acemn PJ et l (1997) Cervicl pregnncy: pst nd future. Ostet Gynecol Surv 52:45 59

22 376 R. Forstner nd A. Schneider 22. Ktok ML, Togshi K, Koyshi H et l (1999) Evlution of ectopic pregnncy y mgnetic resonnce imging. Humn Reprod 14: Nishino M, Hykw K, Kwmt K et l (2002) MRI of erly unruptured pregnncy: detection of gesttionl sc. J Comput Assist Tomogr 26: Filhstre M, Dechud H, Lesnik A et l (2005) Interstitil pregnncy: role of MRI. Europ Rdiol 15: Riley GM, Bcook C, Jin K (1996) Ruptured mlignnt ovrin tumor mimicking ectopic pregnncy. J Ultrsound Med 15: Kuligowsk E, Deeds L Lu K (2005) Pelvic pin: overlooked nd underdignosed gynecologic conditions. Rdiogrphics 25: Mthis SD, Kuppermnn M, Liermn RF et l (1996) Chronic pelvic pin: prevlence, helth-relted qulity of life, nd economic correltes. Ostet Gynecol 87: Umeok S, Koym T, Togshi K et l (2004) Vsculr dilttion in the pelvis: identifiction with CT nd MR imging. Rdiogrphics 24: Prk SJ, Lim JW, Ko YT et l (2004) Dignosis of pelvic congestion syndrome using trnsdominl nd trnsvginl sonogrphy. AJR Am J Roentgenol 182: Hrick H, Reinhold C, Ascher SM (2004) Ovrin dysgerminoms. In: Hrick H, Reinhold C, Ascher SM (eds) Gynecology top 100 dignoses. WB Sunders Compny, Amirsys, Slt Lke City, pp Rozenlit AM, Ricci ZJ, Tuvi J et l (2001) Incompetent nd dilted ovrin veins: common CT finding in symptomtic prous women. AJR Am J Roentgenol 176: Gulti MS, Pul SB, Btr A et l (2000) Uterine rteriovenous mlformtions: the role of intrvenous dul phse CT ngiogrphy. Clin Imging 24: Witlin AG, Mercer BM, Sii BM (1996) Septic pelvic thromophleitis or refrctory postprtum fever of undetermined etiology. J Mtern Fetl Med 5: Dunnihoo DR, Gllspy JW, Wise RB et l (1991) Postprtum ovrin vein thromophleitis: review. Ostet Gynecol Surv 46: Svder S, Otero RR, Svder BL (1988) Puerperl ovrin vein thromosis: evlution with CT, US, nd MR imging. Rdiology 167: Qune LK, Kidney DD, Cohen AJ (1998) Unusul cuses of ovrin vein thromosis s reveled y CT nd sonogrphy. AJR Am J Roentgenol 171: Kuik-Huch RA, Heisch G, Huch R et l (1999) Role of duplex color Doppler ultrsound, computed tomogrphy, nd MR ngiogrphy in the dignosis of septic puerperl ovrin vein thromosis. Adom Imging 24: Pulson EK, Kldy MF, Ppps TN (2003) Suspected ppendicitis. N Engl J Med 348: Andersson RE, Hugnder A, Thulin AJ (1992) Dignostic ccurcy nd perfortion rte in ppendicitis: ssocition with ge nd sex of the ptient nd with ppendectomy rte. Eur J Surg 158: Ro PM, Rhe JT, Novelline RA (1997) Sensitivity nd specificity of the individul CT signs: experience with 200 helicl ppendicel CT exmintions. J Comput Assist Tomogr 21: Horrow M, White DS, Horrow JC (2003) Differentition of perforted from nonperforted ppendicitis t CT. Rdiology 227: Nitt N, Tkhshi M, Furukw A et l (2005) MR imging of the norml ppendix nd cute ppendicitis. J Mgn Reson Imging 21: Oto A, Ernst R, Shh R et l (2005) Right-lower-qudrnt pin nd suspected ppendicitis in pregnnt women: evlution with MR imging initil experience. Rdiology 234: Coen LP, Groot I, Hns L et l (2004) MRI for cliniclly suspected ppendicitis during pregnncy. AJR Am J Roentgenol 183: Birchrd KR, Brown MA, Hyslop WB et l (2005) MRI of cute dominl nd pelvic pin in pregnnt ptients. AJR Am J Roentgenol 184: Ferzoco LB, Rptopoulos V, Silen W(1998) Acute diverticulitis. N Engl J Med 338: Horton KM, Corl MF, Fishmn EK (2000) CT evlution of the colon: inflmmtory disese. Rdiogrphics. 20: Young-Fdok T, Pemerton JH (2005) Clinicl mnifesttions nd dignosis of colonic diverticulr disese. www. UpToDte.com. Cited 21 April Kng JY, Melville D, Mxwell JD (2004) Epidemiology nd mngement of diverticulr disese of the colon. Drugs Aging. 21: Pereir JM, Sirlin CB, Pinto PA et l (2004) Disproportionte ft strnding: helpful CT sign in ptients with cute dominl pin. Rdiogrphics 24: Ro PM (1999) CT of diverticulitis nd lterntive conditions. Semin Ultrsound CT MR 20: Ls JD, Srr MG, Fishmn EK et l (1988) Complictions of cute diverticulitis of the colon: improved erly dignosis with computerized tomogrphy. Am J Surg 155: Cintplli KN, Chopr S, Ghits AA et l (1999) Diverticulitis versus colon cncer: differentition with helicl CT findings. Rdiology 210: Coen LP, Groot I, Blickmn JG et l (2003) Right colonic diverticulitis: MR ppernce. Adom Imging 28: Gelrud A, Crdens A, Chopr A (2005) Epiploic ppendgitis. Cited 21 April Ro PM, Novelline RA (1999) Cse 6: primry epiploic ppendgitis. Rdiology 210: Pereir JM, Sirlin CB, Pinto P et l (2005) CT nd MR imging of extrheptic ftty msses of the domen nd pelvis: techniques, dignosis, differentil dignosis nd pitflls. Rdiogrphics 25: Pickhrdt PJ, Bhll S (2005) Unusul nonneoplstic peritonel nd superitonel conditions: CT findings. Rdiogrphics 25: Furukw A, Sotome T, Ymski M et l (2004) Crosssectionl imging in Crohn disese. Rdiogrphics 24: Willims DR, Coller JA, Cormn ML et l (1981) Anl complictions in Crohn s disese. Dis Colon Rectum 24: Rollndi GA, Curone PF, Bislde E et l (1999) Spirl CT of the domen fter distension of smll owel loops with trnsprent enem in ptients with Crohn s disese. Adom Imging 24: Gore RM, Blthzr EJ, Ghhremni GG et l (1996) CT