Pelvic Pain? Cause Beyond the Ovary

Transcription

1 Pelvic Pain? Cause Beyond the Ovary Catherine Kirkpatrick Consultant Sonographer United Lincolnshire Hospitals Trust

2 Aims Consider not all pelvic pain is ovary or uterus related Explore some non gynae causes of pelvic pain Ultrasound assessment Consideration of inclusion into a standard pelvic assessment?

3 The Request USS Pelvis: Pelvic Pain? Ovarian? Cause Put the curvy down and back away!!!! We need to examine the bowel!

4 Bowel Common Bowel Conditions Giving Rise to Pelvic/Iliac Fossa Pain RIF LIF Appendicitis Ileitis (Crohn s) Caecal and Ileocaecal tumours (including lymphoma) Diverticulitis Diverticulosis Distal Colitis Sigmoid tumours

5 Appendicitis Accuracy of clinical evaluation of acute appendicitis is low especially in the young female (Üeberrüeck et al. 2004) Incredibly variable appearances of the normal appendix leads to false positives Operator dependant

6 The Appendix Graded Compression Technique 3.5 Mhz probe starting point to locate the Caecum which is usually gas containing Most often the appendix is located caudally to the ileocaecal valve.however is quite variable!

7 Normal Appendix High frequency linear probe Compressible thin walled Compared with the terminal ileum, there is no peristalsis Can be seen in up to 70% of patients (according to the literature..).. Purposely excluded and normal measurement of an appendix although some literature use 4mm

8 Appendicitis Increased diameter, non compressible Top Tips Take with a pinch of salt: unreliable unless other features are also present. Top Tips Be careful not slip off the appendix rather that compress Also in focal appendicitis the appendix may not be enlarged and unless the length of the organ is completely imaged this could be missed

9 Appendicoliths Appendicitis Creeping fat/echogenic inflamed mesenteric fat which may be hyperaemic Localised effusion/free fluid Enlarged/reactive lymphadenopathy

10 Appendicitis

11 Appendicitis - Chronic

12 Overview of gut and mesentery Colon Picture Frame (High Frequency linear) Sigmoid Left iliac Fossa Ileocaecal Right Iliac Fossa Terminal ileum and appendix Jejunum Crohn s Disease Stomach/Duodenum/Oesophagus SMA and central small bowel mesentery Mow the lawn Picture Frame

13 Bowel Inflammation Can affect any part of the GI tract Ileocaecal (45%) Terminal Ileum (20%) Colon (25%) Extensive small bowel involvement (5%) Anorectal, oral, gastroduodenal (5%) Crohn s Disease Chronic relapsing inflammatory condition Unknown aetiology Increasing incidence Western prevalence Slight Female Predominance

14 Diagnostic Features Crohn s Disease Mural thickening Mesenteric fat wrapping Ulceration - Apthous -Fissures - Cobblestoning Skip lesions Fistulation Mesenteric Lymph Nodes Mesenteric plethora (Comb Sign) Acknowledgement: Dr R Beable - Consultant GI Radiologist Plymouth

15 Crohn s Disease Acknowledgement: Dr R Beable - Consultant GI Radiologist Plymouth

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17 Crohn s Disease

18 Large Bowel Ischemic Colitis Sigmoid Diverticulosis- faecolith Images Marconi & Bianchi

19 Caecal Tumour

20 Epiploic Appendagitis Acute epiploic appendagitis is a selflimited inflammation of the appendices epiploicae Presentation :? Ovarian torsion /Acute pelvic pain not typical of appendicitis

21 Epiploic Appendagitis Epiploic (or omental) appendages are peritoneal pouches filled with adipose tissue that arise from the serosal surface of the colon They are attached by a vascular stalk They frequently arise in association with colonic diverticula Composed of adipose tissue and blood vessels, the appendages typically have a length of cm Typically only seen on imaging when inflamed

22 Epiploic Appendagitis

23 Omental Infarction Omental infarction is a rare cause of acute abdomen resulting from vascular compromise of the greater omentum This condition has a non-specific clinical presentation and is usually managed conservatively. The term along with epiploic appendagitis is grouped under the broader umbrella term intraperitoneal focal fat infarction.

24 Omental Infarction

25 Rectus Sheath Haematoma Vague and non specific pelvic pain May be some Tachycardia Hypotension Fall in Hbg levels Direct tears to the rectus muscles Damage to the inferior epigastric artery or its branches Minor trauma to those on anti-coag Tx

26 Rectus Sheath Haematoma X

27 Hernia Inguinal hernias are more difficult to detect in women clinically Women often have occult, non palpable inguinal herniae causing pelvic pain Indirect inguinal hernia is the most common hernia in women Pelvic floor herniae may be seen on MRI

28 Hernia

29 Pyelonephritis Urological Causes Interstitial cystitis

30 Calculi

31 X

32 Chronic Nerve Damage Ilioinguinal neuralgia entrapment From previous surgery such as hernia repair/ C- Section Pudendal Neuralgia Excessive compression and repeated minor trauma e.g. from keen cyclists, horse-riding Damage following childbirth Previous pelvic surgery or Pelvic trauma/#

33 Psychosocial Issues Chronic pelvic pain (CPP), a common condition particularly in reproductive-aged women, causes disability and distress, and significantly compromises quality of life and affects healthcare costs. Depression /Anxiety/ Low mood Drug/Alcohol Addictions Previous abuse patients Ultrasound has value in exclusion

34 18 y/o female Final Case Dec 16 :RIF pain 2/12? Tubo-ovarian cause Ultrasound: The uterus, endometrium and both ovaries appear normal. The urinary bladder was empty therefore could not be assessed. No adnexal mass or free fluid seen. Nov 17: Significant W/L and continued RIF pain. Ultrasound for SB US? SB Crohn s No Significant abnormal results in all blood tests or urinalysis performed between Dec 16 & Dec 17

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37 Conclusions Pelvic Pain isn t always a gynaecological issue We can t assess everything it possibly could be! But we can be aware. And perhaps check the possibility of other causes in some cases In our practice pelvic pain with a negative gynae scan usually has the urinary tract assessed..& Thoughts Thinking: the process of considering or reasoning about something using thought or rational judgement; intelligent.

38 References Collins, DC. The length and position of the vermiform appendix: a study of 4,680 specimens. Ann Surg 1932; 96: Google Scholar, Crossref, Medline Rettenbacher, T, Hollerweger, A, Macheiner, P. Outer diameter of the vermiform appendix as a sign of acute appendicitis: Evaluation at US. Radiology 2001; 218: Google Scholar, Crossref, Medline Park, NH, Park, CS, Lee, EJ. Ultrasonographic findings identifying the faecalimpacted appendix: differential findings with acute appendicitis. BJR 2007; 80: Google Scholar, Crossref, Medline Lim, HK, Lee, WJ, Lee, SJ. Focal appendicitis confined to the tip: diagnosis at US. Radiology 1996; 200: Google Scholar, Crossref, Medline Rodgers, PM, Verma, R. Transabdominal ultrasound for bowel evaluation. Radiol Clin North Am 2013; 51: Google Scholar, Crossref, Medline

39 References Marconi G & Bianchi G Ultrasound of the Gastrointestinal Tract. Springer. London

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