ACUTE PELVIC PAIN 강릉아산병원영상의학과 이은혜

Gynecologic PID Ruptured ovarian cyst Adnexal torsion Acute pelvic pain Pregnancy-related Ectopic pregnancy Placental abruption Nongynecologic Acute appendicitis Diverticulitis Urinary stone

Contents Ovaries & fallopian tubes Common causes of acute pelvic pain - pelvic inflammatory disease - ruptured ovarian cysts -adnexaltorsion -ectopicpregnancy

Ovaries Ellipsoid Ovarian fossa - on lateral pelvic wall - btw. ext. iliac vs. anteriorly & int. iliac vs. posteriorly

Ovaries 3~4 cm during reproductive age Dominant follicle : up to 2 cm Corpus luteum (CL) cyst - sonolucent if no int. bleeding - may persist over next 4~5 days - gradually involutes if not pregnant

Fallopian Tubes Interstitial portion - approximately 1 cm length - right & left cornus of uterus - echogenic line arising from endometrial canal Isthmus, ampulla, and infundibulum - not visible unless tubal pathology or free fluid Endosalpingeal folds

Pelvic inflammatory disease

PID Pathogenesis: ascending infection - endometritis salpingitis/toc/toa Classic clinical triad : lower abdominal pain, fever, vaginal discharge Common organisms: gonococci, chlamydia, enteric bacteria After abortions or deliveries

Ultrasound findings of PID Tubal inflammation - tubal wall thickening - pyo/hydrosalpinx Extension to ovaries cogwheel sign incomplete septa beads-on-a-string sign - tubo-ovarian complex vs. TO abscess Free pelvic fluid

Findings of ovarian extension Tubo-ovarian complex (TOC) Tubo-ovarian abscess (TOA)

Fitz-Hugh-Curtis syndrome

Fitz-Hugh-Curtis syndrome RUQ pain and perihepatitis in associated with PID Chlamydial (mainly) or Gonococcal salpingitis Bacterial spread along right paracolic gutter or through lymphatic system Hepatic capsular enhancement on CT (arterial phase)

Ruptured ovarian cysts

Hemorrhagic corpus luteum cyst May rupture peritoneal irritation Severe pelvic pain of abrupt onset & symptoms of acute blood loss vascularity during luteal phase Young women DDx: ruptured tubal pregnancy

Hemorrhagic CL cyst: US Degree of clot formation & lysis - hypoechoic - intracystic echogenic portion: retracted blood clot - fine lace-like int. echo or fluid-debris level: clot lysis Hypervascular ring on color Doppler

Ruptured hemorrhagic CL cysts Thick-walled, irregular-shaped ovarian mass -echogenic - fluid-fluid level - fine reticular pattern - convex-bordered clot Free pelvic fluid with variable echo

Adnexal torsion

Pathogenesis Partial or complete rotation of ovarian pedicle obstruction of venous & lymphatic drainage congestion and edema of ovary increased hydrostatic pr. of ovary impaired arterial supply hemorrhagic infarction

Adnexal torsion Adolescent & young women Underlying ovarian mass (esp. teratoma) or nonneoplastic ovarian/parovarian cyst More common in right side 10-40% previous episode

US findings of adnexal torsion Ovarian enlargement w/ multiple peripheral follicles Complicated cystic ovarian or tubal mass Twisted vascular pedicle: direct sign - broad lig + salpinx + adnexal br of uterine vs -mean φ 4 cm - round echogenic mass w/ concentric hypoechoic stripes - whirlpool sign on Color Doppler

J Ultrsdound Med 2004;23:1643-1649

Ectopic pregnancy

Ectopic pregnancy Classic triad: pain, bleeding, adnexal mass Fallopian tube (esp. ampullar): 95-97%

(+) pregnancy test, no intrauterine G sac ß HCG < 1000-2000 IU/ml ß HCG > 1000-2000 IU/ml Normal early IUP Abortion or EP Serial ß HCG & US Detailed US & F/U!!!

US findings of tubal pregnancy Extrauterine G sac w/ yolk sac or embryo: most specific finding Extrauterine, extraovarian echogenic ring w/o yolk sac or embryo Complex adnexal mass w/o ring configuration: ruptured tubal preg or hematosalpinx (abortion) Free fluid in CDS

Conclusion Acute pelvic pain & US - Don t avoid TVS!!! - nonspecific imaging findings - detailed history taking