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: Genital / Reproductive system female, Pelvis, Abdomen, CT, Ultrasound, Diagnostic procedure, Education and training, Pathology DOI: 10.1594/ecr2015/C-2451 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. www.myesr.org Page 1 of 15
Learning objectives To describe and illustrate the spectrum of tomodensitometric (TDM) findings of pelvic inflammatory disease (PID). It is important to be familiarized with these different possible findings - especially the early ones - not only to accurately differentiate this disease with others with overlapping features, specifically in a clinical scenario of abdominal or pelvic pain in young women, but also in making a correct diagnosis and, consequently, a timely treatment. Background Pelvic inflammatory disease (PID) is an infection of the superior genital female tract, usually by an ascendant route. Neisseria gonorrhoeae, Chlamydia trachomatis and polymicrobial flora are the most frequent pathogens involved. The infection gives rise to an inflammatory process involving the cervical canal, uterine cavity, fallopian tubes, ovaries and pelvis. It can also involve by contiguity or reactive inflammation adjacent abdomino-pelvic structures, like the small and large bowel, excretory renal system and the superior quadrant of the peritoneal surfaces (Fitz-Hugh-Curtis syndrome). It is a frequent pathology affecting women, particularly young women. Other risk factors are low social status, multiple sexual partners, high coital frequency and the use of an intra-uterine device or other forms of pelvic instrumentation. The latter gain special significance in older women. Clinically, it may be asymptomatic or manifest as a spectrum of signs and unspecific symptoms, from vague constitutional symptoms to abdominal or pelvic pain, vaginal discharge, dyspareunia, dysuria, fever, and others. Due to the lack of specificity of these symptoms, it can mimic other medical or chirurgical pathologies, like acute appendicitis, acute diverticulitis, ileo-colitis, ectopic pregnancy, and others, from which it must be differentiated. Consequently, and attending to the fact that laparoscopy, the standard diagnostic technique, being invasive and expansive, is rarely done in this setting, imaging methods come here particularly important, and CT is often required in this scenario. PID may lead to serious clinical consequences like infertility and ectopic pregnancy and is treatment with antibiotics. Surgery gains special importance when there are complications. Page 2 of 15
Findings and procedure details The spectrum of ultrasonographic features is thoroughly known and amply described. The opposite is seen with respect to TDM ones. At an advanced and progressed staged of the disease TDM findings are easy to recognize and appear as tubo-ovarian and pelvic abscesses. It is important to recognize the possible TDM findings of special significance, mainly the early and subtle ones, which frequently go unnoticed and unrecognized. At an early stage of the disease these are reflected by edema with densification of the pelvic adipose planes, obscuration of the normal fascial planes and thickening of the utero-sacral ligaments, with or without mild signs of oophoritis, salpingitis, endometritis and/or cervicitis and with or without accumulation of endocavitary, tubal and/or pelvic fluid. At a subsequent stage, these signs are more pronounced and the fluid is complex, culminating in the formation of visible tubo-ovarian or pelvic abscesses. A promptly and timely diagnosis and treatment are extremely important, attending to the possibility of serious consequences of the disease. Deserving special mention are ectopic pregnancy, infertility and chronic pelvic pain, which are due to fibrosis, damage and occlusion of involved structures - particularly fallopian tubes - seen at a chronic stage. Contiguous inflammatory involvement of the large and small bowel and ureters may be a cause of functional or mechanical obstruction. Other possible complications are FitzHugh-Curtis syndrome and ovarian vein thrombosis. Attending to the fact that PID generally manifests with unspecific signs and symptoms several diagnosis hypothesis can be set in these clinical scenario. From a clinical and radiological perspective, PID must be differentiated from other possible mimicking conditions. Deserving mention are other inflammatory conditions as ileo-colitis, acute appendicitis, diverticulitis and acute epiploic appendagitis; and pathologies with a different nature as ectopic pregnancy and neoplastic lesions, mainly those of an intestinal origin, like those affecting the colon and rectum. Images for this section: Page 3 of 15
Fig. 2: Early PID Page 4 of 15
Fig. 3: Early PID with small bowel involvement Page 5 of 15
Fig. 4: PID with oophoritis and pyosalpinx Page 6 of 15
Fig. 5: PID with pyosalpinx Page 7 of 15
Fig. 6: Advanced PID with a tubo-ovarian abscess Page 8 of 15
Fig. 7: Advanced PID Page 9 of 15
Fig. 8: Advanced PID with abscess and contiguous inflammation of the ovarian vein path Page 10 of 15
Fig. 9: Differential diagnosis - Ulcerative colitis Fig. 10: Differential diagnosis - Diverticulitis Fig. 11: Differential diagnosis - Appendicitis with perforation and abscess Page 11 of 15
Fig. 12: Differential diagnosis - Appendicitis Fig. 13: Differential diagnosis - Ectopic pregnancy Fig. 14: Differential diagnosis - Acute epiploic appendagitis Page 12 of 15
Fig. 15: Differential diagnosis - Mucinous appendicular tumor Page 13 of 15
Fig. 16: Differential diagnosis - Rectal cancer Page 14 of 15
Conclusion The spectrum of ultrasonographic findings of PID is well known and extensively described, unlike the TDM findings. The TDM evaluation is frequently sought in young women with PID, according to the lack specificity of the clinical manifestations. The need to achieve a correct diagnosis and a prompt and timely treatment is emphasized, not only because is a frequent pathology that affects young women of childbearing years but also because it may have potentially serious complications. Personal information E. Matos: MD Radiology resident at the Department of Radiology of Hospital Centre of Vila Nova de Gaia/Espinho. Corresponding author: elizabeth.cabral.matos@gmail.com A. T. Almeida: MD Radiology specialist at the Department of Radiology of Hospital Centre of Vila Nova de Gaia/Espinho. D. Castelo: MD Radiology resident at the Department of Radiology of Hospital Centre of Vila Nova de Gaia/Espinho. References Reviewed bibliography: Sam J. W., Jacobs J. E., Birnbaum B. A. 2002. Spectrum of CT Findings in Acute Pyogenic Pelvic Inflammatory Disease. RadioGraphics, 22:1327-1334. Page 15 of 15