adenexal pathology inflammatory dx

Question 1

what is the most common preventable cause of infertility in the US?

Answer 1

PID

Question 2

what infection occurs bilaterally and can affect the uterus,endometrium, fallopian tubes ovary and broad ligaments?

what are these termed when infected?

Answer 2

PID

Uterus
– Myometrium termed myometritis
– Serosa termed parametritis
 Endometrium termed endometritis
 Fallopian tubes termed salpingitis
 Ovary termed oophoritis
 Broad ligaments termed parametritis

Question 3

~ home man women seek treatment fo rPID / yr

how many become infertile?

Answer 3

1 million

100,000

Question 4

what are some risk factors/etiologies associated w/ PID?

Answer 4

Women with a history of
 Sexually transmitted diseases (STD STD’s) or
s) sexually transmitted infections (STIsexually STI’s) s)
 Young age when becoming sexually active
 Multiple sexual partners
 Douching
 IUD use
 Complication of post post-abortion or childbirth
 Dilation & Curettage (D & C)

Question 5

what are usual cuses for PID?

Answer 5

Bacterial infection from
 Neisseria gonorrhea (a majority of bacterial cause)
 Chlamydia trachomatis (a majority of bacterial cause)

– Other organisms and even more than one
kind of bacteria together also can cause PID
 Escherichia coli (E-Coli)
 Streptococcus
 Haemophilus influenza

Question 6

how is PID spread?

Answer 6

The infection is spread via the mucosa of the pelvic organs through the cervix into the uterine endometrium (endometritis), out the fallopian tubes (salpingitis) to the area of the ovaries and peritoneum
 As the tube becomes obstructed, a pyosalpinx develops
 Sexual transmission is the most common form of
infection, other routes of infection are possible
– Examples
 The string from the IUD provides a route for bacterial
iinnffeeccttiion.  Types of invasive instrumentation procedure in the pelvis, post
abortion

Question 7

what are the infection pathways for PID?

Answer 7

Question 8

what is teh infection spreading?

Answer 8

PID

Question 9

who is the most susceptible to PID?

Answer 9

“Sexually active women under age 25 are at
risk as well because the cervix (opening to the
uterus) of teens and young women has
greater susceptibility to STIs. This may be
because the cervix of teenage girls and young
women is not fully matured, increasing their
risk for STIs linked to PID PID” quote NIH

Teenage & adult women
– More common in African African-American & Hispanic
women

Question 10

wht are some clinical findings associated w/ PID?

Answer 10

Most common finding is pain, which can be severe
– Any of the following
 May be asymptomatic early in disease
 Irregular vaginal bleeding
 Febrile
 Shaking/chills
 Vaginal discharge that may have an odor
 Dysparneuia
 Painful urination
 Pain with cervical manipulation
 Rebound tenderness
 Pain in the upper right abdomen (rare) due to Fitz
Fitz-Hugh Hugh- Curtis syndrome (Fitzhugh Fitzhugh-Curtis I I’ve seen it both ways)

Question 11

what are these lab findings associated with?

– Leukocytosis
– Laboratory documentation of cervical infection with N gonorrhea or Chlamydia trachomatis
– Elevated erythrocyte sedimentation rate (ESR) with tubo tubo-ovarian abscess (TOA) due to severity of infection
– Elevated C-reactive protein level

Answer 11

PID

Question 12

what type of pathology can be associated w/ PID?

name some.

Answer 12

acute, subacute or chronic

Salpingitis  Hydrosalpinx  Pyosalpinx
– Parametritis
– Pelvic peritonitis
– Tubo-ovarian abscess (TOA)
– Endometritis
–
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
– Endometriosis

Question 13

what can repeated episodes of PID cause?

Answer 13

 “Scarring in the fallopian tubes and other pelvic organs
can also cause chronic pelvic pain (pain lasting for months
or even years). You are more likely to suffer infertility,
ectopic pregnancy, or chronic pelvic pain if you have repeated episodes of PID. PID.” Quote NIH

Question 14

what varies depending on if the pathology is acute, subacute or chronic.

Answer 14

pain associated w/ PID

– Most common finding is pain, which can be severe
– May be asymptomatic early in disease
– Irregular vaginal bleeding
– Febrile
– Shaking/chills
– Vaginal discharge that may have an odor
– Dysparneuia
– Painful urination
– Pain with cervical manipulation
– Rebound tenderness
– Metrorrhagia or dysmenorrhea
– Constipation
– Infertility

Question 15

what is an inflammation of a fallopian tube?

Answer 15

salpingitis

Note the redness associated with acute inflammation & pus coming out of the fallopian tube

Question 16

wht does this describe

Serous secretions / fluid within the fallopian tube
– Variable size
– Occurs secondary to PID, endometriosis or
postoperatively due to adhesions in the tube (note the white scar tissue on the diagrams)

Answer 16

hydrosalpinx – Large amount of fluid in tube

Question 17

what can happen w/ the fallopian tube in PID?

Answer 17

Pus within an inflamed fallopian tube

Large amount of pus in tube & adhesions (white scar tissue)

Question 18

what does this look like?

Answer 18

parametritis - Infection within the broad ligament and the
uterine serosa

Question 19

what is an Inflammation that involves other pelvic
structures like the bowel, bladder, ureter, and adnexa

Answer 19

Pelvic Peritonitis

Question 20

what infection involves the ovary and fallopian tube?

Answer 20

TOA tubo-ovarian abscess

Question 21

what is this?

Answer 21

TOA

Question 22

what does endometrities most ocmmonly occus iwth?

Answer 22

– PID
– Patient in postpartum state ( Due to premature rupture of membranes  Long labor  Retained products of conception)
– Following instrumentation into the uterus

Question 23

what is also known as violin string adhesions?

Answer 23

Fitz-Hugh-Curtis Syndrome (Perihepatitis)

Question 24

what is Fitz-Hugh-Curtis Syndrome (Perihepatitis)?

what % of PID pt does this occur in?

clinical symptoms?

labs?

Answer 24

Infection traveling up the paracolic gutters resulting in a peri peri-liver capsulitis
 Only occurs in 3 – 10% of PID patients

 Lower abdominal pain / RUQ pain / right
pleuritic chest pain / vaginal discharge / fever
– Cervical motion and adnexal tenderness
– LFT’s usually normal

– Liver / biliary ultrasound usually normal
– “Highly elevated LFT LFT’s suggest another etiology since LFT s LFT’s are nearly normal in FHC syndrome syndrome”

Question 25

what does a normal fallopian tube look like. how about salpingitis?

Answer 25

– Normally the tube is atortuous, echogenic structure – Total width 8 mm to 10 mm – Difficult to identify unless it is surrounded by fluid – No lumen is seen unless it is fluid filled Distended fallopian tubes – Swollen/thickened walls with characteristic serpiginous/tortuous shape  May only see lumen of tube if associated with hydrosalpinx or pyosalpinx  Is a common mimicker or both diverticulitis and appendicitis

Question 26

what does this look like?

Answer 26

salpingitis - On this TV US it looks like an inhomogeneous enlarged inflamed ovary

Question 27

what is this?

Answer 27

hydrosalpinx ## Footnote Tube is dilated with anechoic fluid (serous secretions) – Amount of fluid varies – Usually bilateral – Thin walls secondary to dilation – Must be able to follow the dilated tubes on real real-time and prove it connects by documenting on the connection on the image

Question 28

explain what you see

Answer 28

hydrosalpinx fluid enhances posteriorly – The echoes seen in the tube are caused by artifacts and this is not pus

Question 29

what is this?

Answer 29

Salpingitis & Hydrosalpinx There may be several combinations of inflammation seen in one patient – The thickened wallsthickened walls of the tube are easily identified by arrows and by the anechoic fluid in the lumen of the tube  This patient has both salpingitis & hydrosalpinx  Note how the sonographerelongated the tube

Question 30

what is this?

Answer 30

pyosalpinx Tube is dilated with fluid & debris or low low- level echoes inside – The pus may not transmit the sound and have poor sound transmission  Note this one has posterior enhancement

Question 31

what is a thickened fallopian tube indicative of?

Answer 31

acute dx (hydro or pyosalpinx) \*A fold or scar tissue may be seen within the tube giving the appearance of a complex mass

Question 32

how can you tell the difference b/t bowel and tube?

Answer 32

– A dilated tube can be distinguished from fluid fluid-filled bowel loop by lack of peristalsis – Change the machines frame rate to observe motion easier – Careful oblique angulations of the transducer are necessary to trace the pathway of the tube – The sonographer should be sure not to confuse the dilated tube with a dilated ureter or prominent vessel

Question 33

what is the measurement for acut inflammation of the fallopian tubE? what does this thickening resemble?

Answer 33

\> or = 5 mm – “Cogwheel Cogwheel” sign  On cross cross-section the tube with thick wall appears like a cogwheel may appear as a complex mass

Question 34

what does the following describe – “Beads on a string string” sign  On a cross cross-section there are hyperechoic mural nodules, measuring 2 2-3 mm are seen within the fluid fluid-filled distended tube which are the endosalpingeal folds

Answer 34

Hydrosalpinx & Pyosalpinx

Question 35

what us findings would you expect to find w/ pelvic peritonitis

Answer 35

– Pus in the cul cul-de de-sac with debris – If the abscess collection has gas forming bubbles within, it may be difficult to delineate well with US because the beam is reflected from the area of interest

Question 36

if a pt has \_\_\_\_\_\_ Patients may not be able to tolerate a TV exam if they have cervicitis – They present with RUQ pain and other symptoms of PID

Answer 36

Fitz-Hugh-Curtis Syndrome (Perihepatitis)

Question 37

what is this? describe it sonographically.

Answer 37

Fitz-Hugh-Curtis Syndrome (Perihepatitis) Typical parallel violin string appearance (white arrowheads) in ascites (anechoic fluid denotes all of the septations surrounding the uterus

Question 38

what is this? describe it.

Answer 38

TOA Complex, multiloculated mass in adnexa or posterior cul cul-de de-sac Thick-walled complex mass with irregular margins – Unilateral or bilateral – Fluid in adnexal/cul cul-de de-sac – Debris of TOA combined with adnexal fluid, may have gas forming organism resulting in loss of normal sonographic tissue planes

Question 39

DDX for TOA the below: The uterus is in the middle with thickened endometrium (probable endometritis) – She has bilateral adnexal masses  Right side (orange circle) differential diagnosis is TOA versus pyosalpinx (note the wall thickness – blue arrow) to prove it the sonographer would need to elongate it into a tube  The left side (green circle) resembles any complex mass with the patients history TOA is the best differential

Answer 39

– Ectopic pregnancy – Endometrioma /endometriosis – Appendictis – Ovarian torsion – Hemorrhagic cyst or corpus luteum  Other problems to consider are – Mittelschmerz, urolithiasis, inflammatory bowel disease and mesenteric adenitis

Question 40

\_\_\_\_\_ – May appear on US  Normal  Endometrial thickening, irregular or prominent (example from previous slide)  Endometrial fluid or pus – May be in posterior cul cul-de de-sac too  Air in endometrial cavity if gas causing bacteria present

Answer 40

Endometritis

Question 41

fyi

Question 42

what is this?

Answer 42

Chronic – Adhesions – Note the diagram has extensive adhesions matting the entire pelvis!

Question 43

\_\_\_\_  Treatment includes antibiotics, drainage of abscesses & surgery  “According to CDC, health care providers should start treatment in sexually active young women and other women at risk for STIs if they have motion tenderness of the uterus, ovaries, fallopian tubes, or cervix. cervix.” quote NIH

Answer 43

PID

Question 44

What is the best differential diagnosis for this adnexal image?

Answer 44

``` The tube (T) is distended and elongated and filled with debris representing pus (pyosalpinx) ```  The ovary (O) is a complex mass similarly filled with pus and it has indistinct borders showing representing a TOA

Question 45

What is the best differential diagnosis for this adnexal mass?

Answer 45

This is a well well-defined homogeneous mass with low low-intensity echoes and acoustic enhancement  Best differential is an Endometrioma (chocolate cyst)

Question 46

What is the best differential diagnosis for this 34 year old with pelvic fullness and pain during her periods?

Answer 46

Endometriosis With bleeding within the tissue  Complex mass with blood flow  Symptoms do NOT warrant a diagnosis of PID  Need to start putting together all of the pathology we have covered thus far