Often the mass can show diffuse low attenuation, which indicates necrosis of the fibroid. Kataoka ML, Togashi K, Inoue T, Fujii S, Konishi J. Overlap in the presenting features of acute gynaecologic disease and gastrointestinal disease remains a significant challenge in the emergency department and imaging plays an important diagnostic role. Laparoscopic management of adnexal torsion. Ultrasound can identify dilated fallopian tubes containing heterogenous fluid with echogenic debris; features typical of pyosalpinx. Complications of untreated PID can have serious implications for the patient and include infertility, ectopic pregnancy, chronic abdominal pain and the development of tubo-ovarian abscesses requiring surgical intervention. National Library of Medicine They occur in 20-40% of females above 30years of age.

Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women.

Sometimes a fluid debris level may also be seen and often, as the clot matures, it may attach to the wall of the cyst, giving it a thick-walled appearance [2, 5, 7]. MRI shows very high signal intensity on T1-weighted images due to the sebaceous component, which is characteristic of dermoid cyst. Cystic teratomas may appear cystic with hyperechoic areas or hyperechoic densities on ultrasound with loss of through transmission [17]. Patient presented to the accident and emergency department with a 1-day history of acute right iliac fossa pain and diarrhoea. The use of Doppler sonography can be used to diagnose adnexal torsion. There are bilateral adenexal cysts that contain low-level echogenic material and have a tubular configuration (white arrows). Acute presentation of endometriosis. Haskins T, Shull BL. The fallopian tubes may be folded and demonstrate areas of tube tapering, and intraluminal small linear echogenic foci may be visualised (Fig. There may also be eccentric or diffuse poor contrast enhancement of the internal solid component or thickened wall [33] (Fig. In rare cases, diagnostic delay can cause peritonitis or fatal thrombophlebitis. Imaging of acute pelvic pain. The new PMC design is here!

Bethesda, MD 20894, Web Policies Endometriosis involves the ovary in more than half the cases (up to 80%). Organisms such as sexually transmitted Chlamydia trachomatas and Nissera gonorrhoea are causative agents in developing ascending cervicitis. This patient presented to the emergency department with pyrexia, lower abdominal pain and diarrhoea. 6a, b). On MRI, haemoperitoneum following haemorrhagic cyst rupture will be seen as variable signal intensity free peritoneal fluid with areas of both low and high signal intensity depending on the extent of blood clot formation.

Transvaginal ultrasound of the left ovary demonstrates a cyst with typical lacelike reticular internal echoes (large white arrow). This feature can be a cardinal sign of tube thickening. a Transvaginal ultrasound demonstrates an ovarian cyst with an area of homogeneous internal echogenicity typical of an endometriotic cyst (black arrow). These features are in keeping with degenerative change of a uterine fibroid. On MRI, T1 hyperintense cysts with T2 shading or multiple T1 hyperintense cysts regardless of the T2 signal intensity increase the sensitivity and specificity of diagnosis [23] (Figs. On CT, the free peritoneal fluid has a relatively high attenuation and, on delayed CT images, there may be contrast-enhanced blood pooling in the pelvis. 9). Sagittal T2-weighted images demonstrate the prolapsing leiomyoma extending into the endocervical canal, and frequently show the stalk and its uterine attachment (Fig. In the case of haemorrhagic ascites, the signal intensity is higher than urine on T1 and lower on T2. Contrast-enhanced CT and MRI may demonstrate reduced enhancement in the twisted ovarian mass, another diagnostic feature of torsion (Table1). 2nd edn. Tomography scanners and computed radiography are not routinely used but are important to recognise key features. The In the acute stage, the haemorrhage is isoechoic in relation to the ovarian stroma and this can often be similar in appearance to an enlarged ovary. Pelvic inflammatory disease with pyosalpinx on ultrasound. The https:// ensures that you are connecting to the Computed tomographic and magnetic resonance features of gynecologic abnormalities in women presenting with acute or chronic abdominal pain. Presentation with a ruptured endometriotic cyst is uncommon but significant as emergency surgery may be required due to severe abdominal pain caused by peritoneal irritation resulting from the flow of the contents of the cyst [21]. However, between 9% and 26% of adnexal torsions occurs in normal-sized ovaries and have normal appearances on ultrasound [2729]. MRI is the most effective modality for characterisation of fibroid degeneration. The pregnancy status of the patient must always be established, in order to exclude ectopic pregnancy and to avoid using imaging modalities, which pose a risk to the foetus. The smaller right-sided cyst may be the site of rupture as the ruptured cyst may be small or difficult to visualize following rupture. Adnexal mass with pelvic pain. It is important that adnexal torsion is diagnosed early as delay can lead to complications such as loss of adnexa or the ovary with the associated fertility problems. MRI appearances show high signal intensity centrally within the fibroid on T1-weighted images consistent with blood, with reduced signal at the periphery on T2-weighted images secondary to haemosiderin deposition (Fig. Ovarian teratomas: tumor types and imaging characteristics. Pelvic inflammatory disease with pyosalpinx on MRI. MRI appearances of submucosal pedunculated leiomyomas can demonstrate a broccoli sign with heterogeneous signal due to the characteristic stalk linking the herniating fibroid with the endometrial cavity (Table1). Patient presented with intermenstrual vaginal bleeding and severe lower abdominal pain. 8600 Rockville Pike The differential diagnosis includes a complex ovarian mass. A characteristic whirlpool sign may be seen on colour Doppler where a corkscrew appearance of a twisted vascular pedicle is apparent. Sonography of obstetric and gynecologic emergencies: Part II, Gynecologic emergencies. Smooth enhancing cyst wall. MRI can provide important clinical information for pre-surgical planning [38, 39].

It usually affects women in the reproductive age group and accounts for 25% of visits to the emergency departments with gynaecological pain. Common presenting symptoms of this condition include chronic pelvic pain, dyspareunia, dysmenorrhoea and infertility [7, 13, 19]. The complex cyst is thick walled and there is adjacent fat stranding. Typically, high T1 material is seen within the cyst. 5a, b). Huchon C, Fauconnier A. Adnexal torsion: a literature review. Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvic pain: spectrum of CT findings. CT and MR imaging features of adnexal torsion. a CT following iv contrast administration demonstrates bilateral low-density cystic lesions (white arrows). It is also common for sufferers to have vaginal discharge and cervical excitation on examination. Lee YR. CT imaging findings of ruptured ovarian endometriotic cysts: emphasis on the differential diagnosis with ruptured ovarian functional cysts. May be multiple, Ruptured endometriotic cyst may be associated with loculated dense ascites often confined to the pelvic cavity due to adhesions, Typically T1 hyperintense cysts with T2 shading; frequently bilateral. Rha SE, Byun JY, et al. The patient presented to the emergency department with acute abdominal pain and vaginal bleeding. When performing ultrasound, it is important to exclude the presence of intraperitoneal fluid in order to exclude haemorrhagic cyst rupture. Kaakaji Y, Nghiem HV, Nodell C, Winter TC. Acute abdominal pain related to the gynaecological tract is a common presentation in the emergency department. Chronic fibrotic changes in pouch of Douglas may be seen, May be undertaken due to acute pain with unclear diagnosis, Not indicated unless the adnexal mass is considered indeterminate, Doppler whirlpool sign with corkscrew appearance of twisted vascular pedicle and an enlarged ovary with peripherally located follicles, Oedema of ovarian stroma. Tubo-ovarian abscesses frequently cause anterior displacement of the broad ligament as the mesovarium is positioned more posteriorly, and this can assist in making the diagnosis [37]. Most cystic teratomas are asymptomatic but 3% may present as torsion and more rarely as dermoid cyst rupture. 7a). MRI shows haemorrhagic cystic lesions as bright on T1-weighted and intermediate to low on T2-weighted images. b Sagittal T2-weighted image demonstrates marked enlargement of the right ovary with high T2 signal intensity in keeping with stromal oedema (white arrow).

ab Transvaginal ultrasound of both adenexa. A haemorrhagic ovarian cyst is suspected if a patient presents with symptoms of acute lower abdominal pain, tenderness and in some cases ascites [24]. St Barts & The London NHS trust, St Bartholomews Hospital, West Smithfield, London, EC1A 7BE UK. Spontaneous prolapse of pedunculated uterine submucosal leiomyoma: usefulness of broccoli sign on CT and MR imaging. MRI can also detect smooth wall thickening of a twisted ovarian mass in cases of adnexal torsion [32]. MRI is the most effective imaging modality in the diagnosis of a prolapsed leiomyoma [38]. The role of imaging is in diagnosis of the lesion origin and identification of the stalk and the uterine attachment of the leiomyoma. 1). However, ultrasound has its limitations in trying to identify whether a haematoma is originating from the fallopian tube or from the ovary.

c Axial T1 image with fat saturation shows central low signal intensity (white arrow) surrounded a rim of high signal intensity in the enlarged right ovary consistent with peripheral haemorrhage (black arrow). In addition, the nonspecific characteristics of the presenting pain can often make CT a more attractive first investigation in the acute setting as it can exclude other intra-abdominal causes. Pelvic inflammatory disease (PID) is described as a spread of inflammation from the endometrial cavity and fallopian tubes into the pelvis. Risk factors for the development of adnexal torsion include ovarian tumours (Fig. This can be advantageous when trying to assess whether the haematoma is intraovarian or extraovarian [2]. Adnexal torsion may also be identified using ultrasound and Doppler, although the diagnosis cannot be safely excluded based on imaging alone. Firstly, torsion may be intermittent. Received 2011 Oct 5; Revised 2012 Jan 26; Accepted 2012 Feb 21. A pedunculated submucosal leiomyoma may be detected on clinical gynaecological examination if there is prolapse into the vaginal canal. There may be absence of vascular supply and low level enhancement in the solid component of the ovarian mass, Wall thickening of torted adnexal mass. d Axial T1 fat sat image following gadolinium administration confirms lack of enhancement of the right ovary (black arrow consistent with right ovarian torsion). May be used to differentiate a degenerating fibroid from a complex adnexal mass, Degeneration gives a complex US appearance with areas of cystic change, Degeneration gives cystic hypodense appearance of fibroid mass, Cystic degeneration is seen as complex high T2 signal intensity within a fibroid, Doppler shows circumferential vascularity, Can be difficult to distinguish from a complex ovarian cyst when large, Red degeneration within a fibroid is seen as, high T1 signal centrally due to blood with low T2 signal at periphery due to haemosiderin deposition, Submucosal pedunculated fibroid may extend into endocervix or vagina from a stalk and may tort, Not usually indicated but may be done if diagnosis is uncertain, Not indicated unless the diagnosis is uncertain and US is indeterminate, Clinical signs are key to diagnosis. Tubular configurations are usually indicative of pyosalpinx. Submucosal pedunculated leiomyomas may prolapse through the cervical canal and even the vaginal canal, and typically present with pain and abnormal vaginal bleeding. Before It can be challenging to distinguish whether a lesion arises from the adnexa or another structure like omentum. Mature cystic teratoma, also known as dermoid cyst, is the most common neoplasm of the ovary. a Sagittal T2 image demonstrates a large uterine fibroid with high signal intensity centrally with a very low signal intensity rim suggestive of peripheral haemosiderin. 4c), which is a less common feature of adnexal torsion [32]. The age of the haemorrhage may be estimated by assessing the signal intensity of the haematoma on MRI [1113].

Eur J Radiol Sept 9 [Epub ahead of print] [. The ovary may be grossly enlarged due to oedema (Fig. She had a raised white cell count and CRP. When using MRI to evaluate an indeterminate adnexal lesion following US, it is recommended that sequences include a T1 and fat-suppressed T1-weighted sequence to detect haemorrhage (Fig. and transmitted securely. Two months later she presented to the emergency department with acute onset of right iliac fossa pain with nausea and MRI of the pelvis was performed (bd). The symptoms of pelvic inflammatory disease are general aching pain in the pelvis that varies in severity. The CT appearances of PID are often non-specific with parapelvic fat stranding, a small volume of free fluid and thickened uterosacral ligaments. Develops fine, reticular spider-web or lace-like pattern. Identifying a connection to the uterus is important in making the correct diagnosis, Haemorrhagic fibroid degeneration. On ultrasound, endometriomas have homogeneous low level echogenicity and give an appearance referred to as the ground glass pattern (Fig.

MRI is used for the characterisation of acute gynaecological complications. The cyst itself may have a crenated appearance [14]. CT may show a heterogeneously enhancing mass prolapsing into the vagina and perineum. Conservative laparoscopic management of ovarian teratoma torsion in a young woman. Lee JH, Park SB, Shin SH. Dohke M, Watanabe Y, Okumura A. Initial misdiagnosis of adnexal torsion is common and studies have shown that only 23% to 66% of cases are given the correct presurgical diagnosis [25, 26]. This patient, known to have uterine fibroids, presented to the accident and emergency department with low-grade pyrexia, tachycardia and acute lower abdominal pain.

A long course of antibiotic treatment is the most common treatment of PID.

Mosby. Endometriosis is caused by cyclical bleeding of hormonally responsive endometrial cells present outside the uterine lining. The stalk extends up into the endometrial cavity and typically has multiple linear structures running through it, and the appearance of the stalk and prolapsed fibroid has been described as the broccoli sign [36]. Doppler US may demonstrate the vascular wall and the avascular internal lace-like appearances of a haemorrhagic corpus luteum cyst [8]. Evaluation of ectopic pregnancy by magnetic resonance imaging. US may be normal. Poor contrast enhancement of internal solid components, May be undertaken if patient has acute pain, Not usually indicated. Symptoms usually manifest during the 4th decade [14]. These benign smooth muscle tumours are sensitive to oestrogens, which are thought to be a main contributory factor to fibroid growth over time.

It is an umbrella term, which encompasses endometritis, salpingitis and tubo-ovarian abscesses. Clinical signs of sepsis can make the clinicians more suspicious of PID. Hertzberg BS, Kliewer MA, Bowie JD, et al. Cyst rupture may demonstrate a combination of low and high T1 and T2 free fluid in pelvis, Not indicated unless suspected acute rupture, Ovarian cyst containing groundglass appearance, with homogenous internal echogenicity. As the clot forms, with time the fibrin strands give a typical reticular fine lacy net or spider web pattern (Fig. The site is secure. Degeneration of fibroids gives a more complex US appearance with areas of cystic change and Doppler can show circumferential vascularity. Ultrasound is often the initial diagnostic imaging modality for suspected complications of fibroids. Other conditions that may lead to the development of tubo-ovarian abscess are diverticulitis, appendicitis and tuberculosis [37, 40]. Functional or simple cysts are usually single, less than 6cm in diameter and thin walled (<3mm). Red (or haemorrhagic) degeneration is another type of acute fibroid degeneration seen in pregnancy and in patients on the oral contraceptive pill, caused by thrombosis of the venous outflow and resulting in a rapid increase in the size of the fibroid with acute haemorrhagic infarction. Although CT and MRI are not routinely used to investigate PID complications, these modalities may demonstrate typically bilateral dilated fallopian tubes and inflammatory changes in the adjacent fat planes (Table1). Radiographics 19 Spec No: S131-145 [. The fibroid may become torted and haemorrhagic, and shows heterogeneous signal intensity on MRI, with lack of enhancement following contrast administration (Fig. Acute complications of fibroids are rarely seen but may be serious. The imaging appearances may overlap with ovarian malignancy but the clinical presentation is of sepsis. c Axial T1 fat-saturated image following gadolinium administration demonstrates low signal intensity within the pus-filled cavities and marked enhancement of the inflammatory walls. PMC legacy view However due to similar symptoms and signs with gastrointestinal and urinary tract pathologies, it is frequently used as the initial imaging modality and recognition of features of gynaecological complications on CT is important. It should be remembered that haemoperitoneum and haemorrhage with ovarian masses can be demonstrated in other acute emergencies such as a haemorrhagic cysts and rupture. Kim JW, Lee CH, Kim KA, Park CM. The use of Doppler is often used to help distinguish between malignant and benign ovarian cysts. A transvaginal ultrasound is often the first imaging modality in patients who are suspected of having an ovarian cyst haemorrhage. Mage G, Canis M, Menhes H, Pouly JL, Bruhat MA. The role of various gynaecological imaging modalities is vital in aiding clinicians to diagnose acute gynaecological disease, and can help to direct medical and surgical treatment where appropriate. b Sagittal T2 MRI demonstrates a large heterogenous mass (white arrow) arising from the fundus of the uterus (black arrow). Fibroids (leiomyoma) are the most common pelvic tumours affecting females in the fertile age group. b Axial T1 with fat-saturated image shows high signal intensity within the fibroid consistent with haemorrhage (black arrow). b Axial T2 image demonstrates bilateral tubo-ovarian abcesses.

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