Imaging Pearls ❯ OB GYN ❯ Inflammatory Disease
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- “Imaging has limited utility in the diagnosis of endometriosis, as it lacks adequate resolution to identify adhesions or superficial peritoneal implants. Ultrasound is cheap and easy to perform, but user-dependent; MRI is more accurate but considerably more expensive. As CT of the pelvis does not visualize pelvic organs well, it is not useful in the diagnosis of endometriosis. An important role for the CT scan with contrast is to detect ureteral involvement and possible renal insufficiency.”
Invasive and non-invasive methods for the diagnosis of endometriosis Albert L Hsu et al. Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419. - “Endometriosis is a common benign gynecologic disorder, defined by endometrial glands and stroma outside of the endometrial cavity. Endometriosis can be associated with infertility or pain symptoms, including cyclic pelvic pain, dysmenorrhea, dyspareunia, dysuria, and dyschezia. The correlation between lesions and pain symptoms or infertility in endometriosis is poorly understood. There is a wide spectrum of symptom severity, and the stage of endometriosis on laparoscopy correlates poorly with the extent and severity of pain. Some patients with minimal disease have debilitating pain, while other women with severe stage III–IV disease are asymptomatic.”
Invasive and non-invasive methods for the diagnosis of endometriosis Albert L Hsu et al. Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419. - “Endometriomas contain a dense, brown, chocolate-like fluid and are pseudocysts formed by the invagination of endometriosis within the ovarian cortex. Adhesions are usually associated with endometriomas and attach them to nearby pelvic structures. Deep infiltrating endometriosis (DIE) is a nodular blend of fibromuscular tissue and adenomyosis. These lesions are primarily found in the uterosacral ligaments or cul de sac, but may also involve the rectovaginal septum. Patients with DIE may present with deep dyspareunia and various bowel symptoms from diarrhea to dyschezia during menses, depending on the location of the deep lesions.-.”
Invasive and non-invasive methods for the diagnosis of endometriosis Albert L Hsu et al. Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419. - “At laparoscopy, endometriosis may be visualized as peritoneal implants, peritoneal windows, endometriomas, and deep infiltrating nodules of endometriosis which may each be associated with adhesions. The color, size, and morphology of endometriotic lesions are highly variable from person to person. Endometriotic implants in the pelvis occur more often on the left side, although the reason for this asymmetry is not known.”
Invasive and non-invasive methods for the diagnosis of endometriosis Albert L Hsu et al. Clin Obstet Gynecol. 2010 Jun; 53(2): 413–419.
- “Given the nonspecific clinical manifestations, computed tomography (CT) is commonly the first imaging examination performed. General CT findings of early and late-stage PID include thickening of the uterosacral ligaments, pelvic fat stranding with obscuration of fascial planes, reactive lymphadenopathy, and pelvic free fluid. Recognition of these findings, as well as those seen with cervicitis, endometritis, acute salpingitis, oophoritis, pyosalpinx, hydrosalpinx, tubo-ovarian abscess, and pyometra, is crucial in allowing prompt and accurate diagnosis.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Late complications of PID include tubal damage resulting in infertility and ectopic pregnancy, peritonitis caused by uterine and/or tubo-ovarian abscess rupture, development of peritoneal adhesions resulting in bowel obstruction and/or hydroureteronephrosis, right upper abdominal inflammation (Fitz-Hugh–Curtis syndrome), and septic thrombophlebitis.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “At CT, careful assessment of common PID mimics, such as endometriosis, adnexal torsion, ruptured hemorrhagic ovarian cyst, adnexal neoplasms, appendicitis, and diverticulitis, is important to avoid misinterpretation, delay in management, and unnecessary surgery.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Pelvic infection is the most frequent gynecologic cause of emergency department visits, with the number of such visits approaching 350 000 per year in the United States. As many as 70% of the adolescent patients with pelvic inflammatory disease (PID) are diagnosed in the emergency department , and nearly 1 million patients with PID are diagnosed annually in the United States.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Salpingitis should be suspected at CT when the fallopian tubes are thickened, measuring more than 5 mm in axial dimension, and show enhancing walls. Associated free fluid may be depicted within the cul-de-sac. For the diagnosis of PID, the CT finding of tubal thickening was found to have a high specificity of 95%.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Common CT imaging features that distinguish ovarian torsion from PID include an enlarged ovary with a diameter of more than 5 cm, a lack of ovarian contrast enhancement, and uterine deviation toward the affected side.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Salpingitis should be suspected at CT when the fallopian tubes are thickened, measuring more than 5 mm in axial dimension, and show enhancing walls. Associated free fluid may be depicted within the cul-de-sac. For the diagnosis of PID, the CT finding of tubal thickening was found to have a high specificity of 95%.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “The etiology of PID has been linked to sexually transmitted microorganisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, and gram-negative bacteria. Polymicrobial infections account for 30%–40% of reported cases of PID.Tuberculosis and actinomycosis occur much less frequently.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “The most common general CT findings of PID described in the literature are thickening of the uterosacral ligaments, obliteration of fascial planes, free fluid in the cul-de-sac, loss of definition of the uterine border, pelvic fat infiltration or haziness and pelvic edema, reactive lymphadenopathy, and signs of peritonitis.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Endometritis is defined as inflammation of the endometrial lining of the uterus. Endometritis is most commonly seen during pregnancy or
in the postpartum state. In the nonobstetric population, PID and invasive gynecologic pro- cedures are the most common causes of acute endometritis. Along with cervicitis, endometri- tis often represents a subclinical form of PID, with patients being asymptomatic.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Salpingitis is defined as inflammation of one or both fallopian tubes, and it is the most common early acute form of PID. The incidence of salpingitis continues to increase on a worldwide scale. The predominant population affected is young women. Among the spectrum of pathologic conditions of PID, salpingitis is associated with the highest risk of infertility and accounts for most of the ectopic pregnancies related to PID. Concomitant endometritis may occur in as many as 70%–90% of documented cases of salpingitis in nonobstetric patients.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Salpingitis should be suspected at CT when the fallopian tubes are thickened, measuring more than 5 mm in axial dimension, and show enhancing walls. Associated free fluid may be depicted within the cul-de-sac . For the diagnosis of PID, the CT finding of tubal thickening was found to have a high specificity of 95%. Salpingitis should be differentiated from secondary inflammation of the fallopian tubes as a result of nongynecologic processes such as appendicitis or diverticulitis.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “At CT, pyosalpinx manifests either as a serpentine or tubular structure with a thick enhancing wall and complex internal fluid or as a complex cystic mass. Adjacent pelvic edema, periuterine and adnexal fat stranding, and the presence of free fluid in the cul-de-sac may also accompany the findings. Clear identification of ovarian involvement with the infectious process may be difficult at CT, particularly if the degree of tubal distention is severe.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Hydrosalpinx occurs when a fallopian tube fills with serous fluid as a result of distal blockage. The most common cause of hydrosalpinx is previous episodes of PID. Other causes include endometriosis, peritubal adhesions from prior surgeries, tubal cancer, and prior tubal pregnancy. Symptoms of hydrosalpinx are variable, ranging from no symptoms to recurrent lower abdominal or pelvic pain.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Tubo-ovarian abscess is one of the major and serious late complications of acute salpingitis and occurs in as many as 15% of women with PID. Tubo-ovarian abscess represents further progression of infection and inflammation, which results in the formation of a complex cystic and solid mass with complete destruction of the normal adnexal architecture. The ovary and fallopian tube can no longer be delineated. As many as 33% of women diagnosed with tubo-ovarian abscess require hospitalization.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “A common and devastating long-term sequela of PID is damage to the fallopian tubes, manifested as scarring and adhesions within the tubal lumen and adhesions in the peritubal fat. Both of these factors are thought to play a major role in the development of ectopic pregnancies, with PID suspected to be involved in 30%–40% of cases. Because tubal function is impeded, resulting in tubal obstruction and development of hydrosalpinx, infertility is a common complication of PID, with 40%–50% of cases of infertility being attributable to this cause.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Fitz-Hugh–Curtis syndrome, also known as perihepatitis, is a rare complication of PID that
is seen in 1%–30% of cases. This condition is defined as inflammation of the peritoneal capsule of the liver and is believed to result from peritoneal spread of pelvic infection along the right paracolic gutter. Women may present with rapid onset of sharp right upper quadrant pain and tenderness.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Ovarian vein thrombophlebitis may occur as a complication of PID. The right ovarian vein is the affected vessel in 80%–90% of cases. Contrast- enhanced CT demonstrates a distended ovarian vein with an enhancing wall and with low-attenuation intraluminal filling defects. Lack of enhancement of the vein will be observed if the
entire vessel is occluded. Associated inflammatory changes may be seen in the pelvic fat, often accompanied by free fluid. If unrecognized or left untreated, ovarian vein thrombophlebitis may result in septic pulmonary emboli .”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “Endometriosis is a common cause of pelvic pain and infertility, with as many as 30% of women with endometriosis demonstrating tubal involvement at laparoscopy. Ruptured deep pelvic endometriomas release blood products that cause adhesions and fibrosis, which may lead to findings that can mimic PID, such as the development of complex pelvic masses, nodularity of the uterosacral ligaments, and peritubal adhesions with tubal obstruction.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “The differentiation of serous cystadenomas and malignant ovarian neoplasms from a complicated tubo-ovarian abscess can pose a diagnostic challenge. The key imaging findings suggestive of malignancy include a lobulated solid or complex mass larger than 4 cm in diameter, enhancing papillary projections, and walls and/ or septa that measure more than 3 mm thick. Multiplanar reformatted images may facilitate recognition of the tubular nature of a complex mass, thus helping to identify it as a tubo-ovarian abscess.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596 - “PID is an important and prevalent pelvic infection among women of reproductive age. CT is often the first imaging modality used for evaluation of patients with PID, because the presenting symptoms are vague and nonspecific. An awareness of the various CT imaging findings of early and late PID and their associated complications is crucial to prevent misdiagnosis and ensure optimal patient care. Early detection of PID can reduce the subsequent risk of tube-related infertility, ectopic pregnancy, and pelvic adhesions resulting in chronic pelvic pain.”
Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation Revzin MV et al. RadioGraphics 2016; 36:1579–1596
- Ovarian Vein Thrombosis: Causes
- Postpartum complication
- s/p pelvic surgery
- Post abortion sepsis
- Pelvic inflammatory disease (PID) - Tubo-Ovarian Abscess: CT Findings
- Thick walled mass in an adnexal location with fluid attenuation
- Septa
- Indistinct borders between uterus and adjacent bowel loops
- Anterior displacement of the mesosalpinx
- Gas bubbles within the mass - CT Findings of PID
- Usually normal in cases of uncomplicated, acute salpingitis
- With progression into tubo-ovarian abscess:
- Bilateral thick-walled, low-attenuation adnexal masses, hydrosalpinx, ascites
- Thick septations
- Often with an associated serpiginous structure corresponding to a dilated, pus-filled fallopian tube
- Gas uncommon