Gynecological emergencies in computed tomography (CT)

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1 Gynecological emergencies in computed tomography (CT) Poster No.: C-1267 Congress: ECR 2010 Type: Educational Exhibit Topic: Genitourinary Authors: M. L. Parra Gordo, I. Pena Fernández, L. del Campo del Val, I. Rodríguez San Pedro Baselga, A. Tejerina Bernal, M. Velasco Ruiz; Madrid/ES Keywords: Tuboovarian disorders, Acute female pelvic disease, Uterine disorders DOI: /ecr2010/C-1267 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 28

2 Learning objectives Acute gynecologic pathology (AGP) is characterized by lower abdominal pain, fever, hemoperitoneum, genital bleeding or shock. Physical examination has a limited role. Ultrasound (US) is the most widely used imaging modality in patients with AGP, although results are not always conclusive. Other complementary techniques are: Computed Tomography (CT): rapid acquisition of images, with exposure to ionizing radiation (young women). CT is a technique in expansion in AGP. * Shows gynecological diseases unsuspected * Clarifies unclear US findings * Complete the extension if the injury is not fully displayed in endovaginal US Magnetic Resonance Imaging (MRI): Using fast techniques and fat-suppressed sequences allows their use in AGP. Not always available LEARNING OBJECTIVES 1. To familiarize the radiologists with the findings in CT in the diagnosis and evaluation of acute uterine and ovarian pathology, postpartum complications, patients with suspected hemoperitoneum and pelvic inflammatory disease (PID). 2. CT shows the gynecological diseases that present with abdominal pain, ascites and obstruction. 3. To show the utility of CT in the diagnosis of enterovaginal fistulas. Page 2 of 28

3 Background Our hospital does not have a gynecologist on call, so many women with acute abdominal pain depends on the radiological diagnosis for an immediate therapeutic approach or a hospital transfer. We review abdominal CT scans performed between January 2007 and August 2009 in the emergency departement radiology. Images for this section: Page 3 of 28

4 Fig. 1: University Hospital La Princesa. Madrid. Spain Page 4 of 28

5 Imaging findings OR Procedure details Multidetector CT studies were performed after oral and intravenous administration of contrast material. We performed the contrast infusion pump with a volume of ml at a flow rate between 2-2,5 ml/sec and a delay of sec, with a standard reconstruction interval. The spectrum of diagnoses were: uterine injury, tubal pathology, ovarian lesions and postpartum complications. UTERINE INJURY Myoma: Most common lesion of the uterus. 20% in women > 30 years. US diagnosis. Acute pain if degeneration and torsion. Significant vaginal bleeding by prolapsed submucosal myoma. If hyaline degeneration or necrosis: cystic appearance, with few contrast enhancement and low attenuation areas. (Fig 2) Hydrometrocolpos secondary to a synechiae: 43 year old woman with irregular painful menses and hypermenorrhea in the last two years. Progressive dyspnea of one month evolution with edema, cough and expectoration. nmalaise, skin and mucosal pallor. Tachypneic. Lower limb edema from root members. Red cell blood count 1.63, Hb. 3, VCM 76. Pelvic CT: Uterus presents 20 x 11 cm of diameter with an endometrial cavity about 9 cm thickness, markedly distended both the corpus and the endocervical canal. The uterus contains a high density material and there is no contrast enhancement. (Fig. 2) Uterine leiomyosarcoma grade III: 51 year old woman with increased abdominal perimeter and no bowel movements. Ascites. Pelvic CT: Mass of 20 cm of pelvic origin compressing sigma. Dilated small bowel loops secundary to obstruction. Ascites. Hysterectomy, bilateral oophorectomy, partial small bowel resection and sigmoidectomy. Extraction of 5 l. of ascites. Pathological findings: cytology positive for malignancy. Uterine leiomyosarcoma grade III, infiltrating small bowel and sigma. (Fig.3) Vaginal fistula: Causes: Congenital, surgical (yatrogenic), obstetrics, cancer, infections, radiation and trauma ØTypes: vesicovaginal, rectovaginal, ureterouretrovaginal, peritoneovaginal Secondary to hysterectomy, prolonged expulsive, tumors. In our hospital, there are four cases listed: 3 cervix carcinomas (Fig.4) and 1 acute diverticulitis. TUBAL PATHOLOGY Page 5 of 28

6 Normal tubal anatomy: Ø Ampullar portion <8 mm Ø Isthmian portion <4 mm Ø Infundibular portion <10 mm. It is considered thickened if > 10 mm Tubal torsion:rare cause of abdominal pain, with delayed diagnosis ØMore common in right side (2:1) and periovulation. There are predisposing factors: hydrosalpinx, tubal ligation and pelvic adhesions. CT findings (Fig. 5) Ø Tubal hemorrhage: > 50 Hounsfield Unit (HU) in unenhanced CT Ø Increased tubal diameter > 15 mm Ø Cystic mass, solid or mixed, in contact with uterine horn (yellow arrow) Ø Contralateral normal ovary Ø Thickening of the suspensory ligament surrounding the hypodense mass with mouse tail image Ø Density increase of the adjacent fat Ruptured ectopic pregnancy in right fallopian tube: Patient 30 years old, with urinary infection. Abdominal pain and lower abdominal mass Hb 9.8, WBC 16,680 with neutrophilia. Positive pregnancy test. Pelvic CT: hemoperitoneum. Active bleeding signs in cystic lesion in the right adnexal area (yellow arrows) in Fig.6. Pelvic Inflamatory disease (PID): Affects one million women with annual hospitalizations. Ascending cervicovaginal infection, generally produced by Chlamydia, Neisseria gonorrhoeae, E. coli, Bacteroides, peptococci (30-40% are polymicrobial origin). Risk factors: young women, multiple sexual partners, high coital frequency, IUDs, low socioeconomic status. It is associated with increased risk of ectopic pregnancy, PID, chronic pelvic pain, infertility Clinical findings: 20% afebrile and with no increase in leukocyte level, fever, abdominal or pelvic pain, vaginal secretion, uterine bleeding, dyspareunia, dysuria, nausea, vomiting. Fig. 7. EARLY PID: Pelvic edema with loss of fat planes, uterosacral ligament thickening, endometritis with endometrial enhancement and fluid in the endocervical channel (1), cervicitis with cervical/pericervical enlargement, enhancement and inflammation (2), salpingitis with fallopian tube thickening, oophoritis with ovarian increase with hypercaptation (3) Page 6 of 28

7 Fig. 8. ADVANCED PID. Piosalpinx with dilated fallopian tube with enhancement of the thickened wall and liquid content inside. Pelvic and tubo-ovarian abscess with liquid collection / mixed cystic and solid mass with thick wall, internal septa and gas-fluid or fluid-fluid levels inside. OVARIAN LESIONS Ovarian torsion: Ultrasound is the technique of choice. More common in children with hypermobility and adult women with ovarian masses or ovarian cysts. (Fig. 9) Ovary with increased peripheral follicles, lack of vascularization. CT findings: Uterine deviation toward the side of the torsion, with presence of mass or cyst, ovary large, displaced, ascites, loss of fat planes, increased vascularity (congestion) or hemorrhagic stroke (lack of enhancement, hematoma or gas) Follicular cyst rupture: Female, 27 years old in secretory phase of her cycle. Pelvic pain with negative pregnancy test. In fig. 10, hemoperitoneum in presence of sentinel clot (yellow arrow). Right ovary with increased density (white arrow). Conservative treatment with disappearance of ascites and normal ovaries appearance in ultrasound after 10 days. Endometriosis: Can appear in ovaries, suspensory ligaments of the uterus, peritoneal surface, small and large intestines, ureters, bladder, vagina, surgical scars or pleura. Incidence of 10-15% of women between 25 and 44 years old. Predisposing factors: direct family history, first pregnancy at age over 30 years old, caucasian ethnicity, abnormal uterus. Between 25 and 50% of infertile women have endometriosis. In figure 11, a gyant endometrioma. Hemorrhagic ovarian cyst: (Fig. 12) Hemorrhage in a corpus luteum or follicular cyst. In pelvic CT, mixed density mass with values between HU (white arrow). It is associated to hemoperitoneum with ascites > 50 HU (yellow arrow), cyst wall enhacement after IV contrast injection. Contrast extravasation in pelvis in late phase. CT excludes liver adenoma rupture Ovarian tumors: Fig. 13. Twisted fibrotecoma. Women 57 years old with acute abdominal pain. In pelvic CT, heterogeneous mass in right iliac fossa displacing the uterus (U). In surgery, ovarian fibrotecoma with signs of congestion and necrosis was found. Page 7 of 28

8 Fig. 14. Giant teratoma with Rokitansky nodule. Female, 70 years old with abdominal mass. In pelvic CT, heterogeneous mass with areas of fat density and a solid nodule inside. Fig. 15. Left adnexal cystadenoma. Woman 87 years old with bowel subocclusion. Pelvic mass on examination. In pelvic CT, cystic mass without septa or solid poles. Fig. 16. Bilateral cystadenocarcinoma. Woman 36 years old. Abdominal growth simulating advanced pregnancy. Pelvic mass on examination. In pelvic CT, cystic mass with solid poles. Ascites. POSTPARTUM COMPLICATIONS Ovarian vein thrombosis. Female 46 years old with eutopic delivery 10 days ago. Lower abdominal pain. On CT, ovarian vein thrombus is displaced (white arrow), enlarged postpartum uterus and abdominal free fluid. (Fig.17) Ovarian torsion. 37 year old woman in the fourth day postpartum. Severe abdominal pain. US inconclusive. In pelvic CT: Postpartum uterus. Enlarged right ovary without contrast enhancement. Pathological diagnosis: Piece of right oophorectomy with hemorrhagic infarction and abscess related to ovarian torsion. (Fig. 18, yellow arrow) Images for this section: Page 8 of 28

9 Fig. 1: 40 year old woman with mass, adominal and pelvic pain. Uterine leiomyomas with hyaline degeneration and free fluid. In surgery, torsion of subserous fibroid. Page 9 of 28

10 Fig. 2: Hydrometrocolpos secondary to a synechiae Page 10 of 28

11 Fig. 3: Uterine leiomyosarcoma grade III, infiltrating small bowel and sigma. Page 11 of 28

12 Fig. 4: Woman 72 years old. Subtotal hysterectomy. Paravesical right mass. Hyperdense contrast of sigma in the vagina. Enterovaginal fistula secundary to carcinoma of cervix. Page 12 of 28

13 Fig. 5: Female 23 years old. 6 days abdominal pain located in the right iliac fossa, with nausea, vomiting and fever of 38 C. In surgery, uterine horn with marked hemorrhage, congestion and foci of hemorrhagic necrosis. Diagnosis: Right fallopian tube torsion. Page 13 of 28

14 Fig. 6: Pelvic CT: Hemoperitoneum. Active bleeding signs in cystic lesion in the right adnexal area (yellow arrows) Page 14 of 28

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16 Fig. 7: Early PID: Endometritis with endometrial enhancement and fluid in the endocervical channel (1) Cervicitis with cervical/pericervical enlargement, enhancement and inflammation (2) Oophoritis with ovarian increase with hypercaptation (3) Page 16 of 28

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18 Fig. 8: Advanced PID: Pelvic and tubo-ovarian abscess Liquid collection / mixed cystic and solid mass with thick wall, internal septa and gas-fluid or fluid-fluid levels inside Fig. 9: Twisted Teratoma (yellow arrow) Page 18 of 28

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20 Fig. 10: Female,27 years old in secretory phase of her cycle. Pelvic pain with negative pregnancy test. In fig. 10, hemoperitoneum in presence of sentinel clot (yellow arrow). Right ovary with increased density (white arrow). Page 20 of 28

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12: Hemorrhage in a follicular cyst: mixed density mass with values between 45-100 HU (white arrow) It is associated to

22 Fig. 11: Female 33 years old. Abdominal pain and left flank mass. In abdominal CT, cystic mass of 26 cm. Pathological diagnosis: Endometrioma Fig. 12: Hemorrhage in a follicular cyst: mixed density mass with values between HU (white arrow) It is associated to hemoperitoneum with ascites > 50 HU (yellow arrow) Fig. 13: Twisted fibrotecoma. Women 57 years old with acute abdominal pain. In pelvic CT, heterogeneous mass in right iliac fossa displacing the uterus (U). Page 22 of 28

23 Fig. 14: Giant teratoma with Rokitansky nodule. Female, 70 years old with abdominal mass. In pelvic CT, heterogeneous mass with areas of fat density and a solid nodule inside. Page 23 of 28

16: Bilateral cystadenocarcinoma. Woman 36 years old.

24 Fig. 15: Left adnexal cystadenoma. Woman 87 years old with bowel sub-occlusion. Pelvic mass on examination. In pelvic CT, cystic mass without septa or solid poles. Fig. 16: Bilateral cystadenocarcinoma. Woman 36 years old. Abdominal growth simulating advanced pregnancy. Pelvic mass on examination. In pelvic CT, cystic mass with solid poles. Ascites. Page 24 of 28

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26 Fig. 17: Ovarian vein thrombosis. Female 46 years old with eutopic delivery 10 days ago. Lower abdominal pain. On CT, ovarian vein thrombus is displaced (white arrow), enlarged postpartum uterus and abdominal free fluid. Fig. 18: 37 year old woman in the fourth day postpartum. Severe abdominal pain. US inconclusive. In pelvic CT: Postpartum uterus. Enlarged right ovary without contrast enhancement(yellow arrow). Pathological diagnosis: Piece of right oophorectomy with hemorrhagic infarction and abscess related to ovarian torsion. Page 26 of 28

27 Conclusion Although ultrasound is the first imaging technique is the initial evaluation of abdominalpelvic pain in women, CT shows characteristic findings in many gynecological diseases and guidance on the clinical management of these patients. Pelvic masses diagnoses involves the transfer of patients to the maternal reference hospital, except ruptured ectopic pregnancy or tubo-ovarian torsion, that require urgent surgery. Personal Information ML ParraGordo, MD Emergency Radiology Department. Hospital Universitario La Princesa. Diego de León Madrid, Spain References 1. Cano Alonso R, Borruel Nacenta S, Díez Martínez P, Navallas Irujo M, Ibáñez Sanz L, Sabía Galíndez E. Role of multidetector CT in the management of acute female pelvis disease. Emerg Radiol 2009; 16: Page 27 of 28

28 2. Dohke M, Watanabe Y, Okumura A, Amoh Y, Hayashi T, Yoshizako T et al. Comprehensive MR imaging of acute gynecologic diseases. RadioGraphics 2000, 20: Skinner S, Voyvodic F, Scroop R, Sanders T. Isolated tubal torsion: CT features. Clin Radiol 2001; 56: Rha SE, Byun JY, Jung SE, Jung JI, Choi BG, Kim BS et al. CT and MR imaging features of adnexal torsion. RadioGraphics 2002; 22: Bennett GL, Slywotzky CM, Giovanniello G. Gynecologic causes of acute pelvis pain: Spectrum of CT findings. RadioGraphics 2002; 22: Sam JW, Jacobs JE, Birnbaum BA. Spectrum of CT finding in acute pyogenic pelvic inflammatory diseases. RadioGraphics 2002; 22: Kim SH, Kim SH, Yang DM Kim KA. Unusual causes of tubo-ovarian abscess: CT and MR imaging findings. RadioGraphics 2004; 24: J. Sandoval, C. Santa, P. Paz. Fístulas vaginales: 173 casos observados en 18 años. Ginecol Obstet. 1998; 44: Page 28 of 28

Pelvic inflammatory disease - spectrum of tomodensitometric findings

Pelvic inflammatory disease - spectrum of tomodensitometric findings Poster No.: C-2451 Congress: ECR 2015 Type: Educational Exhibit Authors: E. Matos, A. T. Almeida, D. Castelo; Vila Nova de Gaia/PT Keywords: