Nongynecological causes of acute and chronicpelvic pain. Amela Sofić UKC Sarajevo Bosnia and Herzegovina

Size: px

Start display at page:

Download "Nongynecological causes of acute and chronicpelvic pain. Amela Sofić UKC Sarajevo Bosnia and Herzegovina"

Estella George
5 years ago
Views:

1 Nongynecological causes of acute and chronicpelvic pain Amela Sofić UKC Sarajevo Bosnia and Herzegovina

2 One of the most challenging problems in a clinical routine is the pelvic pain It is useful to classify pelvic pain as acute or chronic, because differ in their differential diagnoses The pelvic pain can be ofgynecological and nongynecological origin The most common cause of nongynecological pain: -appendicitis -diverticulitis -urinary calculus -IBD -inguinal hernia

Appendicitis-Conventional radiography Plain radiographsare normal in many

on plain radiographic films(in 10%) Barium enema For evaluation of chronic

acute appendicitis Advantage Readily available Disadvantages High incidence

3 Appendicitis-Conventional radiography Plain radiographsare normal in many patients with acute appendicitis An appendicolith is the most specific sign on plain radiographic films(in 10%) Barium enema For evaluation of chronic appendicitis Its use is not necessary in the case of a clear presentation of acute appendicitis Advantage Readily available Disadvantages High incidence of nondiagnostic examinations Radiation exposure Insufficient sensitivity Invasiveness

Appendicitis-Ultrasound Lack of radiation exposure, Non-invasiveness, Short acquisition time

Doppler US in detecting increased vascularity of the apendix High accuracy 90%; sensitivity 78%;

apendix) Difficulties keeping the probe in the same location for a long time The US depends on the

4 Appendicitis-Ultrasound Lack of radiation exposure, Non-invasiveness, Short acquisition time Graded-compression in a step-wise approach and aims to optimize visualization of the appendix Color Doppler US in detecting increased vascularity of the apendix High accuracy 90%; sensitivity 78%; specificity 83% Disadvantages Intestinal peristalsis Pulsation of the iliac artery (when it is near apendix) Difficulties keeping the probe in the same location for a long time The US depends on the operator Sensitivity of US is lower than of CT/MRI Complementary MRI or CT may be performed if diagnosis remains unclear

diagnostic accuracy of 95-98%;sensitivity 91%; specificity 90% Disadvantages Radiation exposure The potential for anaphylactoid

5 Appendicitis-Contrast-enhanced CT CT findings in chronic appendicitis are the same as those in acute appendicitis To evaluate adult patients Time-efficient Cost-effective Good characterization of periapendicular inflammatory changes, apscesand perforation High diagnostic accuracy of 95-98%;sensitivity 91%; specificity 90% Disadvantages Radiation exposure The potential for anaphylactoid reaction if intravenous (IV) contrast is used Lengthy preparation time if oral contrast is used Patient discomfort if rectal contrast is used

Appendicitis-MRI Better visualization of abnormal appendices and adjacent inflammatory processes Demonstrate the extent ofinflammatory infiltration Visualization of the appendix in an atypical

6 Appendicitis-MRI Better visualization of abnormal appendices and adjacent inflammatory processes Demonstrate the extent ofinflammatory infiltration Visualization of the appendix in an atypical location Delineation of pathology Operator independence Ease of examination of obese patients Disadvantages Use of IV contrast Claustrophobic patients The inability to observe an appendicolith in the lumen The inability to differentiate between gas and an appendicolith in the perforation site

It is primary methodfor patients with chronic diverticulitis Barium enema can

7 Left colonic divertikulitis- Conventional radiography Plain radiographs Free intraperitoneal air (perforation) Signs of bowel ileus or obstruction Barium enema It is primary methodfor patients with chronic diverticulitis Barium enema can superbly depict : -diverticula -colonic mucosa -colonic lumen -colonic spasm muscle hypertrophy

Sensitivity of 77 to 98% and a specificity of 80 to 99% Can be used if CT is not available Inexpensive,

8 Left colonic divertikulitis-ultrasonography The ultrasound finding is ratherunclear and depends on the stage of the disease US is not as widely used as a first imaging test US is occasionally useful in diagnosing of acute diverticulitis Sensitivity of 77 to 98% and a specificity of 80 to 99% Can be used if CT is not available Inexpensive, noninvasive,readily available Disadvantage May not be helpful in excluding diverticulosis or diverticulitis because of interference due to bowel gas

Left colonic divertikulitis-ct CT is the technique of choice for the detection of acute diverticulitis CT has replaced barium enema in evaluation of diverticulitis CT is superior to

exclud other a pelvic disease CT help to make modified Hinchey stage The grade of severity of acute diverticulitis CT sensitivity for diverticulitis is 79 to 99% Disandvantages CT

9 Left colonic divertikulitis-ct CT is the technique of choice for the detection of acute diverticulitis CT has replaced barium enema in evaluation of diverticulitis CT is superior to US in the detection of free air and deeply located or small fluid collection Can help in evaluating : -inflammatory disease -complications such as bowel obstruction, abscess Can exclud other a pelvic disease CT help to make modified Hinchey stage The grade of severity of acute diverticulitis CT sensitivity for diverticulitis is 79 to 99% Disandvantages CT may fail to demonstrate early, mild cases of diverticulitis Potential difficulty in differentiating diverticulitis from colon carcinoma Limited availability in certain regions of the world

Radiation-free imaging MRI is also comparable with CT to identify alternative

10 Left colonic divertikulitis-mri MRI findings is similar to CT: -bowel wall thickening -pericolic stranding -presence of diverticula - complications Radiation-free imaging MRI is also comparable with CT to identify alternative diagnoses Diagnose acute diverticulitis, with sensitivity of 86 to 94% and specificity of 88 to 92%

Lower ureteric, Vesico-Ureteric Junction stones-plain radiograph For low-dose initial investigation, plain film with ultrasound is used For follow up, plain film is useful when a stone is visible

11 Lower ureteric, Vesico-Ureteric Junction stones-plain radiograph For low-dose initial investigation, plain film with ultrasound is used For follow up, plain film is useful when a stone is visible Calcium stones 1-2 mm can be seen Cystine stones 3-4 mm may be depicted Disadvantages Smaller calculi and/or radiolucent stones may go undetected 5% of stones are not visible on plain film radiographs Uric acid stones are usually not seen Obstruction/hydronephrosis cannot be adequately assessed

artefact on colour Doppler - colour comet-tail artefact When stones are seen, with a specificity as high as 90% Disadvantages Some

12 Lower ureteric, Vesico-Ureteric Junction stones-ultrasound Stones are visiblein the distal ureter at or near the UVJ, especially if dilatation is present Good for characterizing lucent filling defects Features include: -echogenic foci -acoustic shadowing - twinkle artefact on colour Doppler - colour comet-tail artefact When stones are seen, with a specificity as high as 90% Disadvantages Some patients with acute obstruction have little or no dilatation Limited sensitivity for smaller stones than 2 mm USdoes not depict the ureters well

Lower ureteric, Vesico-Ureteric Junction stones-intravenous urography-ivu Provides physiological information related to the degree of obstruction The radiation dose is generally less than CT, but it

13 Lower ureteric, Vesico-Ureteric Junction stones-intravenous urography-ivu Provides physiological information related to the degree of obstruction The radiation dose is generally less than CT, but it is the same size It shows anatomical abnormalities that can predispose patients to stone formation Possibility of delayed recording and use of gravity in a tilted or upright position Distinction of external calcifications, organizational calculus Detection rate as high as 70 90% Disadvantages Can only visualise radiopaque stones (80 90% of stones) Less sensitive to CT, especially for small or nonobstructive stones Intravenous contrast is requiredand can hide stones Lucent stones do not differ from the transitional cell carcinoma or blood clot

Lower ureteric, Vesico-Ureteric Junction stones-ct CT is the modality of choice in the evaluation of acut pelvic urolithiasis CT is faster and more effective in detection

of 96-100% Low-dose CT protocol can be used as the initial imaging technique Disadvantages Stones at the UVJ may be difficult to distinguish from stones in the bladder

a phlebolith soft-tissue rim sign: favours a ureteric calculus CT urography (CTU or CT-IVU) gives both anatomical and functional information With intravenous contrast in a

14 Lower ureteric, Vesico-Ureteric Junction stones-ct CT is the modality of choice in the evaluation of acut pelvic urolithiasis CT is faster and more effective in detection of missed stones on IVU Nonenhanced CT is usually sufficient with the aid of US Stones with attenuation values < 200 HU are visible Sensitivity of 94-97% and a specificity of % Low-dose CT protocol can be used as the initial imaging technique Disadvantages Stones at the UVJ may be difficult to distinguish from stones in the bladder (repeat scan through the UVJ in the prone position) Distinguishing a ureteric calculus from a phlebolith can be challenging Two signs are helpful: comet-tail sign: favours a phlebolith soft-tissue rim sign: favours a ureteric calculus CT urography (CTU or CT-IVU) gives both anatomical and functional information With intravenous contrast in a single acquisition as opposed to the multiple and more dynamic traditional IVU Visualization of other structures in the abdomen is also better with CTU than with traditional IVU

Lower ureteric, Vesico-Ureteric Junction stones-mri MR urography -MRU in case of chronic urolithiasis When CT nor sonography can not explain the complicated state Useful in case of allergy to Iodine

15 Lower ureteric, Vesico-Ureteric Junction stones-mri MR urography -MRU in case of chronic urolithiasis When CT nor sonography can not explain the complicated state Useful in case of allergy to Iodine contrast material or radiation is contraindicated (during pregnancy) The T2w-MRU sequence performed with multiple coronal orientations and diuretic administration is sufficient to identify entirely the non-dilated ureter HASTE MR urography: - allows rapid acquisition of images - has similar accuracy to spiral CT MRU showesureteric calculi 72% of calculi seen by CT MRU sensitivity is93.8% Disadvantages Relative unspecificity of filing defects basedindetecting of stones Stones are not directly visible on MRI because they produce no signal Gadolinium-based contrast is linked with nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)

Inguinal hernia- Computed tomography Using CT scans, the sensitivity in 83%, specificity 67-83% Computed tomography (CT) remains the best available imaging tool for evaluation of

sagittal reformatted images are used for problem solving Many hernias spontaneously reduce if the patient lies relaxed in the supine position during the scan Valsalva maneuver

16 Inguinal hernia- Computed tomography Using CT scans, the sensitivity in 83%, specificity 67-83% Computed tomography (CT) remains the best available imaging tool for evaluation of acute inguinal hernias Visualisation of hernia sac and neck, and signs of edema and inflammation within the hernia sac and bowel wall Axial images examined first, then coronal or sagittal reformatted images are used for problem solving Many hernias spontaneously reduce if the patient lies relaxed in the supine position during the scan Valsalva maneuver during a fast helical sequence may increase sensitivity Useful if another disease process is present that may be mimicking a hernia Disadvantage Diagnosis may depend on finding a fascial defect

Inguinal hernia-ultrasonography Is useful in non-urgent,chronic cases Real-time examination allows to perform Valsalva or other maneuvers that elicit hernia symptom Visualization of peristalsis in

17 Inguinal hernia-ultrasonography Is useful in non-urgent,chronic cases Real-time examination allows to perform Valsalva or other maneuvers that elicit hernia symptom Visualization of peristalsis in herniated bowel, which mayassist in diagnosis Disadvantages Fascial defects are difficult to identify with ultrasound An ultrasound finding may be unspecific in the case of herniation of fat tissue or omentum

18 Generally is not a first-line imaging technique MRI allows for hernia evaluation in multiple imaging planes MRImay be useful in cases difficult to characterize by CT such as Morgagni or traumatic hernias In the future, increased availability of MRI Inguinal hernia- MRI

IBD-Conventional radiography Plain radiographs It is useful in case of obstruction or extraintestinal manifestations Barium enema Useful in the detection of ulcerations cobblestone appearance Usuful

19 IBD-Conventional radiography Plain radiographs It is useful in case of obstruction or extraintestinal manifestations Barium enema Useful in the detection of ulcerations cobblestone appearance Usuful in evaluation of: - tubular narrowed - spasm - sinus tracts and fistula - chronic changes if they are obstructed Barium enema has a 95% accuracy rate in distinguishing Crohn disease from ulcerative colitis

specificityof 95%in the detection of Crohn's disease Doppler shows an increase in vascularity in inflamed bowel segments US

20 USis useful for Crohn's disease in the ileocaecal region with sensitivity up to 95% Candifferentiates the acute ulcerative phase and chronically reparative phase Useful in the extensive extraintestinal manifestations of IBD Sensitivityof 75% and specificityof 95%in the detection of Crohn's disease Doppler shows an increase in vascularity in inflamed bowel segments US Doppler has sensitivity 91.4% and specificity 96.1%, Endoscopic ultrasound of IBD in the pelvis refers to the evaluation of the rectum IBD-Ultrasound

IBD-CT Like MRI, CT can depict: - Segmental thickening, hickened folds due to oedema - -extraluminal

flegmone and abdominal abscesses CT enteroclysis in evaluation IBD of small bowel Sensitivity of CT

acute and chronic IBD Disadvantages Differentiation between peristalsis and skip lesions may be

21 IBD-CT Like MRI, CT can depict: - Segmental thickening, hickened folds due to oedema - -extraluminal lesions, mesenteric and abdominal manifestations - complications such as sinus tracts and fistulas - flegmone and abdominal abscesses CT enteroclysis in evaluation IBD of small bowel Sensitivity of CT enteroclysis is87% and specificityis100% CT colonography is reliableforcolon analysis in distinguishing acute and chronic IBD Disadvantages Differentiation between peristalsis and skip lesions may be difficult Limitation of artefacts are produced by collapsed small bowel loops CT enteroclysis not detect recurrence of disease

Evaluation: - extraintestinal manifestations of IBD

haustration For differentiate active inflammation

in assessing perineal complications Identifying the

supralevator abscesses MRI is superior to CT in the

22 Evaluation: - extraintestinal manifestations of IBD -perianal fistulae -superficial ulceration -loss of haustration For differentiate active inflammation from fibrosis Superior to CT scan and fistulography in assessing perineal complications Identifying the levator ani wich is a landmark for distinguishing supralevator abscesses MRI is superior to CT in the differentiation of fistulous tracts IBD-Routine MRI

IBD-MR colonography,mr enteroclysis Bright bowel wall due to increased signal of water on T2 sequences suggests

colonography MR colonography is an alternative to colonoscopy MR enteroclysis is reliable in evaluation of Crohn's

abnormalities Itis the only method that excludes small bowel inflammatory and noninflammatory disease Can be a first

23 IBD-MR colonography,mr enteroclysis Bright bowel wall due to increased signal of water on T2 sequences suggests disease activity Layered pattern of enhancement on T1 with gadolinium is highly specific for active disease MR colonography MR colonography is an alternative to colonoscopy MR enteroclysis is reliable in evaluation of Crohn's disease of the small intestine of MR enteroclysis It issuperior to MR enterography for detecting Crohn's disease abnormalities Itis the only method that excludes small bowel inflammatory and noninflammatory disease Can be a first line modality Disadvantages of MR enteroclysis Inability to compress bowel in real time Not evaluate superficial abnormalities or fistulas

24 To take home The role of diagnostic imaging in evaluation of Nongynecological causes of acute and chronic pelvic pain is: confirm the diagnosis evaluate the severity and extent of disease exclude alternative diagnoses allow for treatment planning The decision to obtain diagnostic modality depends on: institutional preference available user expertise important influencing factors: patient age patient sex patient body habitus

25 To take home US and CT are the initial imaging test of choice in many cases ButUSis favor for patients due to the absence of ionizing radiation Conventional radiography has limited diagnostic value in the assessment of most patients with pelvic pain MRIis another emerging technique for the evaluation of pelvic pain that avoids ionizing radiation The choice of imaging technique depends on the clinical scenario

US in non-traumatic acute abdomen. Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university

US in non-traumatic acute abdomen Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university Sagittal Orientation Transverse (Axial) Orientation Coronal Orientation Intercostal