Acute Gynecologic Ultrasound Review, Dr. Kathryn McGillen, (12-13-22)
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Today we are honored to welcome Dr. Catherine mcgillan
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for a lecture on acute gynecologic ultrasound.
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Dr. Mcgillan is a graduate from Jefferson Medical College in
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2008.
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And completed residency and Diagnostic Radiology at Brown
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Rhode Island Hospital. She is an associate professor in
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the radiology department at Penn State Health where she
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teaches residents fellows and medical students her research
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focuses on Ultrasound with a focus on collaborating with other
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Specialties on high-end applications such as contrast
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ultrasound elastography and
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endometriosis Imaging
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At the end of the lecture Joint Dr. Mcgillan and
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a Q&A session where she will address any questions you may have on today's topic.
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we can get to as many as we can before our time is up with
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that. We are ready to begin today's lecture.
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Dr. Mcgillan, please take it from here.
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Hi everyone. Thanks for joining me for a
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case-based review of a cute Gynecology ultrasound and I
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do want to thank MRI online for having me.
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And without further Ado, I'm Kate mcgillans. I'm from
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Penn State and Hershey, and I have no relative irrelevant disclosures.
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Okay, objectives. Today. We're going to go over a cute Gynecology
2:01
with an emphasis on ultrasound. We're going to review some
2:04
common indications some common cases. We're also
2:07
going to look at some uncommon and rare entities and
2:10
some some unusual but acute presentation
2:13
of entities that are usually not coming in the acute
2:16
setting meaning you may not otherwise think of this entity in
2:19
the acute setting, but maybe you should
2:22
Okay, so we'll start with the vagina and the labial regions. So our
2:25
first patient comes in febrile with pain and swelling
2:28
in the labial region.
2:29
You can see here with this high frequency linear probe.
2:32
We looked via a trans labial approach
2:35
and you can see just really heterogeneous tissue here
2:38
in the subcutaneous fat in this area. You put
2:41
some color Doppler on some Power Doppler and we can see
2:44
it's very vascular. Normally. You're not going to see a whole lot of
2:47
flow in the subcutaneous fat, but we see a lot here.
2:51
So what this is is a diagnosis of a cellulitis. So
2:54
what we're looking for here and what we see in
2:57
our edema in the soft tissues. Normally, they're pretty homogeneous.
3:00
And we really have a lot of heterogeneity here.
3:03
We're also looking for increased vascularity, which
3:06
we're seeing here that tells us there's some sort of inflammation in
3:09
this area and then of course you're using the ultrasound because
3:12
some a lot of times the cellulitis is going to be clinically apparent. They're
3:15
not going to need radiology for this but they need us to
3:18
look for the abscess or for evidence of gas and the
3:21
soft tissues. And so we don't see a fluid collection here we can rule
3:24
that out gas is going to look like echogenic Foci
3:27
with dirty shadowing behind it. And one thing
3:30
to keep in mind when you're looking at subcutaneous fat are really any fat
3:33
in general when fat is inflamed it gets brighter. So you
3:36
have to not mistake that with the faux side air that you can see
3:39
with the dirty shadowing. So this is all just bright echogenic fat.
3:42
We see vascularity to it. So this is a cellulitis without
3:46
further complication.
3:49
Our next case is worsening pelvic pain
3:52
and a palpable finding on physical exam.
3:55
So what this ultrasound imaging we already have the Doppler box over top of it.
3:58
Again. We're using a high frequency linear probe. We're looking
4:01
via a translabial approach and you can
4:04
see there is a fluid collection this time and what we have
4:07
here. We have a you know, we do have a wall but it's pretty thin. Maybe you
4:10
can see a wall a little bit better up here. We have a fluid fluid
4:13
level within it here and we have no color Doppler
4:16
flow either within the lesion around the
4:19
lesion or in the adjacents of cutaneous fat. We do
4:22
have increased through transmission so we know this isn't a solid
4:25
mass or unlikely to be a solid mass and more
4:28
likely this is a fluid collection here.
4:30
So in this case between the physical exam findings and
4:33
what we're seeing on ultrasound we can confidently diagnose a
4:36
complicated Bartholin gland cyst.
4:39
So to go over this briefly a barthland gland cyst
4:42
it forms because of an obstruction of the
4:45
duct either due to stenosis Stone inspectated mucus
4:49
prior infection or trauma something like that.
4:52
It is the most common of the vulver cyst. So just you know,
4:55
seeing assist in this general area. Most likely to be
4:58
a barcelain gland cyst.
5:00
And oftentimes there asymptomatic, but if they do have symptoms mild
5:03
dyspareunia is the most common one.
5:07
When you see them, they're going to be most commonly a unilocular cyst
5:10
usually arranged from one to four centimeters in size.
5:14
And specifically on an MRI or CT because
5:17
an ultrasound finding the geographic landmarks are
5:20
bit more difficult. So it's going to be along the postal
5:23
lateral wall of the distal vagina, which you can see nicely here on
5:26
this T2 weighted image here. We have our uterus up
5:29
here and then we chill Canal vagina right here bladder right
5:32
here pubic symphysis. And here's our T2 bright cyst same
5:35
one on the left right here. This is very classic location. And this
5:38
is where they should appear to help differentiate from other cysts.
5:43
If they get infected or if they acutely bleed
5:46
that's when patients tend to start to present with something like
5:49
pain.
5:50
And so here's another example. This was a palpable abnormality right
5:53
labial. And you can see in this case. We do have a
5:56
fluid collection, but it looks
5:59
incredibly heterogeneous. It's very complex. We
6:02
do have our increase through transmission here. Maybe the walls a
6:05
little bit thicker than we would normally see. This is something
6:08
definitely want to put your color Doppler box on to see what's going on there.
6:11
In this case. There's not a lot of internal vascularity. We're not
6:14
worried that this is a solid Mass. Although the
6:17
clinical history is going to help us because usually these present pretty acutely
6:20
if they bleed or certain infectious a little
6:23
bit of flow in it, but not a whole lot here either. This one
6:26
was an infected one. We didn't see a
6:29
lot of inflammation around it. So again clinical diagnosis is
6:32
going to help in these particular cases.
6:34
That particular cyst did end up going on to
6:37
MRI.
6:38
Can you can see here on our t2weighted images? It's not as T2
6:41
bright. It's not a simple fluid like it wasn't our prior example
6:44
right here. We're right-sided here. We have a thick wall here
6:47
and just sort of heterogeneously T2 bright signal in
6:50
this.
6:51
Our pre and post contrast we can see there's intrinsic bright
6:54
signal on it. So in either hemorrhaged or
6:57
has some sort of proteinaceous debris within it and there's
7:00
really no contrast on the subtraction. We did image. This is a little bit
7:03
of artifact right there. And that's what we would expect to see in a
7:06
barcelain glances. That was either super infected or
7:09
had blood at some point.
7:12
All right, next case. This is a 58 year old patient who
7:15
presented with chronic pain and discomfort and we got Imaging in
7:18
both Supine and standing these are
7:21
the standing pictures right here and we did it within without valsalva. So
7:24
another superficial high frequency probe
7:27
looking via trans labial approach and we see these anechoic
7:30
structures that somewhat elongate. Maybe
7:33
they connect on a cine clip. If you have them put some
7:36
Power Doppler on this is
7:39
now on the left side and we can see again with the split screen image. We
7:42
have these tubular structures and they have blood flow
7:45
in them, right you can see it's sort of serpentine down here. So what
7:48
we see here a tortuous Serpentine usually Anna
7:51
coax structures, although if they're slow flow in them.
7:54
It can be a little bit hypocholic such as this example right here.
7:58
And these are consistent with varices. Generally. These
8:01
are not going to come in an outpatient or sorry an
8:04
inpatient setting usually but they certainly can if they're complicated.
8:10
In general these are going to be palpable findings patients will
8:13
have an aching dull sort of pain that again is usually chronic
8:16
they can have dispariania and they can
8:19
come in with a vulvodynia.
8:21
You look for dilated veins in the labia majora
8:24
and the menorah.
8:25
These are very frequently associated with
8:28
pelvic varicosities and they are associated with pregnancies most
8:31
commonly in the second trimester. If you
8:34
do develop their varices associated with
8:37
the pregnancy, they often don't resolve afterwards ultrasound itself
8:41
is really not going to be that useful for diagnosing these because
8:44
it's usually clinical diagnosis. It's not really that challenging necessarily
8:47
ultrasound is useful for indeterminate cases
8:50
or when they're Complicated by an acute thrombus. It's
8:53
important to note that most thrombi are going to
8:56
current in either the pregnant woman or the recently postpartum women.
9:00
So here's a companion case. This is a transvaginal Imaging.
9:03
This is not a labial Imaging uterus is
9:06
off to the side over here and our sonographer nicely labeled.
9:09
This is V right here on different cineclipses. You
9:12
could see this was an elongated structure. This was definitely a
9:15
vessel that looks certainly very focal right here, but what
9:18
you can see here is you have some you know hypochoic around
9:21
this echogenic structure and when they
9:24
compress because you can compress with the transvaginal probe and
9:27
pushing over top of the abdomen as well. It incompletely compressed
9:30
right here. So that makes this a thrombus
9:33
right here and so that can be a cause of
9:36
acute left and Axle pain.
9:38
Color Doppler Imaging showed too that there's blood flow to this
9:41
area. There's blood flow in the vein but not within the echogenic thrombus
9:44
right here.
9:47
Here's a different case that I show you just within the same kind
9:50
of veins right here. This is a patient who had end stage
9:53
liver disease and was known to have complicated.
9:57
Varices had a sitees all the
10:00
different end stage type of manifestations and she came in with this left lower
10:03
quadrant acute pain and this is what we found in her inexa. There
10:06
was no separate ovary. So this was presumed to be the
10:09
ovary and what this was was an acutely
10:12
thrombosed ovary due to
10:15
ovarian varices and I don't show you this because I would
10:18
expect anybody to get this but just so that you've seen one and a
10:22
lot of times looking at these in retrospect. The clue is always there on how
10:25
we could figure this one out. In this
10:28
case. You have the echogenic thrombus in these huge dilated vessels and
10:31
you can see areas over here. This does not look like normal ovarian tissue
10:34
over here these tiny little Serpentine vessels. You can
10:37
see them better on color Doppler. This isn't just normal blood flow
10:40
to an ovary. This is a significant almost Serpentine what
10:43
you would expect veracies to look like and no flow
10:46
over here.
10:48
As you can expect this wasn't recognized at the time to be
10:51
what it was because it's a really tricky case and
10:54
she did go on to MRI. This is what it looks like on a
10:57
T2 very expanded T2 dark rim
11:00
This is the pre contrast where you can see all this
11:03
T1 bright intrinsic again is going to be protein or Hemorrhage
11:06
or clot. In this case as was and really
11:09
not very much enhancement to it. Probably some ovarian tissue
11:12
enhancing hair, but that's pretty much it not a very specific
11:15
MRI appearance. If you don't know already that she has various
11:18
sees elsewhere much more helpful too few
11:21
that can look at prior Imaging because you can watch the Pharisees come down
11:24
the left the Nexa and in the Retro perineal space included
11:27
together. This is four years later. We were still
11:30
following this because it wasn't really clear what it was and here's our T2
11:33
Imaging and really dark image right here, but these are
11:36
all T2 flow voids, which again wasn't recognized at
11:39
the time because once you label something a mass
11:42
it kind of stays that way until someone thinks outside of the
11:45
box. Here's our T1 appearance again, four years later. This looks
11:48
very different than when she first presented.
11:51
Still a little hemorrhagic blood material in there and then you have
11:54
this brisk enhancement. So this looks like a mass it still
11:57
looks bad and slowly growing over four years.
12:01
but what this ended up being is if you put on
12:05
Our split screens here for the ultrasound. We had a
12:08
very astute clinician.
12:10
Ask us to do this and you can see all of these vessels. They're all
12:13
connected all of this Doppler flow in it. And
12:16
then we could finally confidently say, you know, these are basically replacement
12:20
of the ovarian tissue with varices. When you
12:23
go back to multiple scans with that Viewpoint in mind,
12:26
you could then go back and figure out the diagnosis and that's
12:29
what it was. This entire time never was a mass.
12:33
So again split screen color Doppler.
12:36
very interesting case
12:40
Okay.
12:40
And moving on with that we'll go on to the ovaries officially.
12:45
So our next patient is a 29 year old presenting to
12:48
the Ed with right pelvic pain.
12:51
And so here's a pretty classic appearance. We have a transvaginal ultrasound
12:54
so high frequency program you can
12:57
see up here is our nine multi curves.
13:00
And we have the right ovary. The ovary volume is large
13:03
right? It's 50 milliliters normal ovaries in
13:06
general should be around 10 milliliters or less that's
13:09
normal. But in this case, we have multiple findings. We have
13:12
this thick rim of tissue right here. Unclear if
13:15
this is a wall or if this is the ovary itself
13:18
that's left. We have this internal structure. That's
13:21
very heterogeneous. One lace like a reticular.
13:24
We have a little bit of free fluid out here next to
13:27
it. We also have increased through transmission throughout this entire process
13:30
including the free fluid next to it. That's conforming to
13:33
the spaces here.
13:35
So we put some spectral Doppler on in this
13:38
case because we always need to roll out torsion. And so the wall again is
13:41
vascular and we can see we have normal venous waveforms nice
13:44
and you know fairly flat lines not a rapid
13:47
velocity. We're less than five centimeters per second. This is a normal
13:50
venous waveform.
13:51
And the arterial waveform again in the rim of this normal, we
13:54
don't have a lot of signal coming in but we see
13:57
a nice low resistance waveform and never goes
14:00
down to Baseline before we get a new curve right here.
14:03
So this is very normal not particularly Rapid or too
14:06
fast as well. This is a nice normal material waveform. This ovary
14:09
is Not Tourist what this is though is a
14:12
classic appearance of a hemorrhagic cyst.
14:14
Okay, so here's a not quite so
14:17
classic way that they can show up. So this is a companion case
14:20
46 years old. We have a coronal non-contrast CT
14:23
which happened a lot especially when we didn't have a lot of contrast in
14:26
this area, you know a few months ago. She comes
14:29
in with right-sided pain and an abnormal CT so non
14:32
contrast difficult to look at gynecologic structures
14:35
in a CT in general let alone without any contrast to help
14:38
us, but we can figure out that this is going to be the uterus right here
14:41
because this is probably a calcified fibroid and so we have this
14:44
right at netzel structure just a little bit heterogeneous with
14:47
this sort of you know, slightly bright band of tissue through
14:50
it. So you have a differential based off of this but not
14:53
much more you can do with it without getting you know, ultrasound or MRI.
14:56
And since we're in the Ed ultrasound is going to be your next
14:59
thing.
15:00
So here we go. So we have a sagittal image of the right ovary right
15:03
here. This looks pretty normal to me so far. She's 46
15:06
years old. We have some you know cortex here. We have
15:09
a follicle here, maybe a little bit of free fluid. This doesn't look
15:12
like the structure so far that we're seeing on CT so our sonographer
15:15
swings over a little bit further and now here is still a
15:18
part of the right ovary right here. We've got some follicles and you
15:21
have this structure and this is you know, a thick
15:24
band of hyper Cove tissue. Maybe this corresponds to
15:27
what we were seeing on the CT right here. So the next question I
15:30
have is this isn't is this an add an Excel mass or
15:33
is this part of the ovary is this maybe a little bit of tissue and it's
15:36
a rising from the ovary organ. Is it something separate that's
15:39
going to change your differential diagnosis?
15:42
So sonographer put on color Doppler and you
15:45
can see there is a vascular bridge between these two structures, right? Here's
15:48
your right. Ovary Here's Your Redneck Soul process or next to
15:51
it next to the ovary and there's a vascular Bridge
15:54
here. So that means this structure is a rising from the right ovary. The
15:57
Doppler box here isn't showing any flow internally within
16:00
this obviously you need an entire Doppler box over it
16:03
to make that diagnosis that there is no internal flow,
16:06
but I'll tell you that this is representative of the rest of it. So
16:09
now we have a structure that didn't separate they did perform
16:12
a perfect. Sorry a pressure maneuver to try
16:15
and separate them to see where they two separate structures or where they want and the
16:18
color Doppler also shows us that it they were one
16:21
structure they're together.
16:23
So I'll show you the sending clip. Here's your ovary right here. Here's that
16:26
you know band of tissue connecting them and then here's the
16:29
separate structure and just how heterogeneous. It really is. I'll play
16:32
that one more time.
16:38
So I didn't really feel like this was a particular classic appearance
16:41
for anything. You know,
16:44
the this was a differential case for me. The over itself looked.
16:47
Okay, so I didn't think this was going to be a normal ovarian torsion,
16:50
but could that thing have been a mass that was exophytic and
16:53
tourist itself or could that be a very preculated
16:56
exopedic hemorrhagic cyst? The patient did
16:59
have a lot of pain and ended up going to the or and it was
17:02
just a pedunculated hemorrhagic cyst in this case.
17:06
So to review hemorrhagic cyst, the classic
17:09
appearance is like the first case that I showed you that lace-like reticular
17:12
pattern. If you see that it's a hemorrhagic cyst
17:15
you're done. They are going to be a vascular. That's the other
17:18
important thing. There's no internal vascularity occasionally their
17:21
exophytic like the second case that I showed you
17:24
and because of that they can act as a lead point for torsion.
17:27
So you want to look at that ovary itself as well to see does
17:30
it look like it's a tourist ovary or is it normal more phylogene?
17:34
This is a hemorrhagic process. So you can absolutely have some
17:37
free fluid and can be a little bit complex because it could be
17:40
a hemorrhagic free fluid.
17:42
And if you're not sure, you know, if you have a case like this that you like I think
17:45
this is all retracting clot. I think we're past the reticular lace
17:48
like pattern now. I think this is just retracting clot. I
17:51
think that's all it is. But you know, I can't tell this a little Doppler flow
17:54
right here or not. You can just get a short interval follow-up,
17:57
you know in six weeks or so a hemoradic cyst. It's small
18:00
enough we'll completely resolved or at the very least
18:03
we'll have significantly decreased in size as the patient gets to
18:06
another cycle and they're menstrual phase. However, the other
18:09
things you'd be considering such as a mass like an endometrioma.
18:13
We'll stay the same size and a mass if
18:16
it's a malignancy will stay the same size or maybe even enlarge a
18:19
little bit. So short interval follow up is reasonable if
18:22
it's not a classic appearance of the hemorrhagic cyst
18:25
if it's a classic hemorrhagic system, no follow-up is needed.
18:29
Okay, next case 33 year old coming to
18:32
the Ed with acute right lower quadrant pain.
18:35
And so as we're looking at this ovary, there's a couple things that you should
18:38
be noticing right off the bat. We have some free fluid out
18:41
here in the corner. We have very heterogeneous stroma, in
18:44
this case centrally and we have some small follicles that
18:47
are somewhat peripheralized in this single picture with
18:50
a little echogenic Rim around some of them and then
18:53
come down to our volume here 47 milliliter over
18:56
again. That's very enlarged. That's not going to
18:59
be normal. We have to have an explanation for it. Do we have an internal
19:02
hemorrhagic cyst? Do we have a mass or is it the entire over
19:05
itself that's enlarged. And in this case, I'm going to tell you I
19:08
think it's the entire ovary that's enlarged.
19:13
So let's put some spectral Doppler waveforms on it because she came in with a
19:16
cute right lower quadrant pain. So that's localized into the right
19:19
ovary.
19:20
Arterial waveforms we don't have a lot of them here, but they look
19:23
pretty normal. Besides that I've got
19:26
a low resistance waveform Rises up comes back down
19:29
never gets back down the Baseline. That's okay. That's that's
19:32
what the normal limits.
19:34
Moving on to the venous waveforms their present
19:37
but they're decreased. We have a lot of patchiness in
19:40
here, right and that's you know, we're writing a good spot in
19:43
the over that ovary isn't really far away from the probe. Maybe
19:46
it's you know artifactual that we can't get it weren't a really
19:49
good spot for this. So this I will call abnormal and also
19:52
looking at the grayscale image itself, right? This does
19:55
not look like the waveforms. Sorry that the color document we
19:58
were seeing on other images, right? It almost looks like they had to crank
20:01
up those settings to get these little dips and dots right here and maybe
20:04
this is almost artifactually we're really struggling to
20:07
find spots to get waveforms here.
20:10
So I think that's abnormal as well.
20:13
So this is a classic case of ovarian torsion.
20:18
Here's our companion case. This is a 32 year old who came in with left floor quadrant
20:21
pain. We see normal venous waveforms. We have an ovary
20:24
here very similar appearance to the other one, even though this is a
20:27
different patient can perfilize small follicles heterogeneous stroma,
20:30
centrally.
20:32
And in this case the arterial waveform is a
20:35
little bit off and we have a higher resistance waveform
20:38
you watch that Peak. It's very rapid never goes
20:41
back down to Baseline, which is good. But this is very rapid that
20:44
I'm starting to worry about that's an abnormal arterial waveform
20:47
and then beyond that more phylogy morphology
20:50
to me is King in these cases. You cannot have
20:53
a torched ovary and have a normal looking normal morphologically
20:56
normal over. It just doesn't happen. So in
20:59
this case again, it's an enlarged ovary. We have these small multiple follicles
21:02
many of them are peripherals. They have this echogenic. Halo
21:05
around them. We have some free fluid around
21:08
it.
21:09
And this was an enlarged ovary. And so we have
21:12
a little bit further Imaging here. I'm going to play this cine clip uterus is
21:15
right here free fluid here and have you your attention right
21:18
to this area right here?
21:20
And so what you're seeing there before we get into the
21:23
ovary itself, which you'll see how large it is. I feel like it looks
21:26
even bigger on this in a clip here. You can just see how abnormal
21:29
that ovary is.
21:32
And I'm gonna play that one more time.
21:34
Focus right here you can see a swirling as we go through
21:37
starting right around now we get this swirling right here.
21:40
That's the whirlpool sign. That's the Twisted.
21:44
Structures blood structures leading to the ovary and
21:47
the torsion there so you won't always see the whirlpool sign
21:50
but when you do see it you can be confident. This is a
21:53
tourist ovary despite what the spectral Doppler does or doesn't
21:56
show
21:57
so let's go over all of these.
21:59
So we have our findings and we have our spectral Doppler findings.
22:02
What happens first is we get a twisting of the ligamentous supports
22:05
that result in a compromise blood supply to
22:08
the ovary.
22:10
So the Venus will compromise first because veins are compressible. Whereas
22:13
arteries you have to use a lot more Force to compress them. So Venus
22:16
is what you'll normally see.
22:19
Get compromised first. You may not see anything keeping that in
22:22
mind. But what will happen is that that venous compromise
22:25
will cause the ovary to enlarge again greater than 10 milliliters
22:28
and it should be asymmetric to the other ovaries.
22:31
So you're gonna get an enlarged over like we have here you're gonna
22:34
get Central heterogeneity and edema like we're seeing here just
22:37
a little bits of heterogeneity. That shouldn't be there.
22:40
And then you're going to get those small peripheralized follicles
22:43
that get pushed out. You can have some right we do
22:46
see some Century, but mostly they're going to go further away.
22:50
After that is when you start to get the abnormal arterial
22:53
waveforms and that's because of all the edema in
22:56
the ovary and enlarges. It stretches the capsule. It
22:59
causes pain, it causes pressure and that results in arterial thrombosis.
23:02
They may be small arteries that we don't necessarily see
23:05
but that causes the ischemia the
23:08
infarction and you see that enlarged ovary. So one
23:11
thing to keep in mind the thing I keep saying keep coming back
23:14
to is the enlarged ovary. That is the most consistent finding
23:17
you pretty much cannot have a torsion if the ovaries
23:20
small at least not an acute torsion. If you have a normal
23:23
sized ovary or small ovary has to be enlarged even if
23:26
you see normal spectral Doppler waveforms.
23:29
but
23:30
again, if you do see abnormal spectral Doppler waveforms that
23:33
increases your confidence knowing that some ovaries will
23:36
still have completely normal spectral Doppler waveform,
23:39
but will be tourists the morphologies more important. But in
23:42
any case, here's your example of an abnormal arterial waveform, which we
23:45
just reviewed there.
23:49
Like I said, some will have preserved flow. Those are the
23:52
ones that tend to do really well in the or right because that ovary is
23:55
still intact. So they have a good chance of keeping that over and not needing
23:58
an oophorectomy.
24:00
So it is important to note that the most common spectral abnormality.
24:03
If you have one is going to be absent or decreased venous
24:06
waveforms. That's the most common one but arterial waveforms
24:09
can be a bit trickier because they can normally be cyclical
24:12
you can have
24:15
Low versus high resistance can be a normal sign in that case. You're going
24:18
to use your symmetry. Look at the other ovary. See what's going on with that
24:21
one abnormal ones that
24:24
are pretty much are always abnormal if you get lack of
24:27
diastolic flow, so this didn't go to Baseline. But if it did at any
24:30
point that is completely abnormal. You can never explain that
24:33
as a sickle cyclical physiologic finding
24:37
If you see the Twisted pedicle of the whirlpool sign, you
24:40
can see it as a targeted hypercoic mass-like
24:43
structure. If the vessels are on one
24:46
side of it. It tends to look more bird beaked and that is very very
24:49
sensitive and very specific. You have a torched over and always
24:52
remember you should see and very commonly do see a bit
24:55
of free fluid or even Hemorrhage because of that ovary Crossing centrally.
25:00
Okay, so let's move on to the next step.
25:02
So this was a 59 year old patient came in with acute right
25:05
lower quadrant pain.
25:07
And here's our Imaging.
25:09
So as we're looking through this this is initially labeled as you
25:12
can see is right over and they starting to you make some
25:15
measurements here, but I would argue this isn't over there's absolutely nothing
25:18
normal about it whatsoever. We have a bowel loop back
25:21
here, you know, there's no variant tissue. This thing is elongated. Is
25:24
this assist with a thick and regular citation doesn't make
25:27
a whole lot of sense. So the sonographer kept
25:30
looking
25:31
and they moved a little bit, you know more lateral and they saw
25:34
the structure that look more soft tissue or a mask. Like they couldn't quite figure out
25:37
what was going on. So they put a speckled Bachelor on it, and you
25:40
can see Venus waveforms.
25:43
And so that you know as a vascular process right there and they swung
25:46
a little bit more lateral because here's part of our structure
25:49
over here and they found a normal looking over it this ovary
25:52
does look different than our other over. She's 59. She's postmenopausal. So
25:55
it is very common that they have few to
25:58
know follicles left at this point on the
26:01
stroma tense. Look a little bit more academic with almost. It's peripheral
26:04
Halo common appearance for a normal postmenopausal ovary
26:07
and we can see here. We only have two measurements, but that looks
26:10
like it's going to be smaller which is again classic for
26:13
postmenopausal. So this is not an over that we're seeing on the other
26:16
Imaging.
26:17
This was an isolated fallopian tube torsion.
26:20
So that can happen separate from the ovarian
26:23
process itself. So here's the same
26:26
image or same patient.
26:28
And I say we're starting right here with the right ovary. And
26:31
then you see this swirling right here very similar to what we saw
26:34
in the torsion case of the ovary and
26:37
then we get into this fluid filled structure. We have a cog wheel
26:40
appearance of thick wall right here. And this is a classic appearance
26:43
of a fallopian tube torsion. I personally think
26:46
this diagnosis can be pretty tricky and ovary right
26:49
here. Here's the twisting think it'd be pretty tricky.
26:52
If you don't see this Whirlpool sign, so you have to know to
26:55
look for it. Your Tech has to go back and look for it. They didn't see it
26:58
or look on your cine Clips to see if you can find that Whirlpool because
27:01
that's gonna cinch the diagnosis for you.
27:04
So fallopian tube torsion, it is not uncommon.
27:08
That it will tourist with the ovary. So
27:11
if you see a tourist morphology the ovary and
27:14
a dilated tubular structure, they both went together, but it's
27:17
definitely possible to tourist just the fallopian tube
27:20
and not the ovary as well.
27:22
The ovaries normal. So in isolation occurs about one and
27:25
one and a half million women so not common but it absolutely can
27:28
and the patients who this tends to happen to
27:31
are people who had a tubal abnormality from previous
27:34
whether it was pelvic inflammatory disease hydrosal
27:37
things tubal ligation a tubal
27:40
Mass something like that.
27:43
Imaging appearance is a dilated thickened tube.
27:47
You can have some internal debris that might be some hemorrhagic material
27:50
that's in there. And you want to look for that vascular pedicle
27:53
that bird beaked appearance and that's what we're showing right
27:56
here. That's what they found there because this a soft tissue mask what's going
27:59
on here. This is sort of that bird beak appearance. So when you
28:02
had the cine clips and you could see that swirl, that's when we
28:05
were able to put it all together. And again, you have to know to look for that because it
28:08
might otherwise be out of your image field of view. It might be
28:11
higher up so they have to look for that.
28:13
Again, here's the hydro salpings part of it where the
28:16
tube itself dilates up filled with fluid and then your classic Cog
28:19
will appearance in the thicken. Wall right here.
28:23
Just to keep in mind. This is more common on the right side than
28:26
it is the left side. They don't know if that's because of the sigmoid mesentery,
28:29
but this is an easy Mist diagnosis
28:32
and commonly is it's called either just a run of
28:35
the mill hydrosal things or maybe a complex ovarian lesion,
28:38
which is kind of where we were starting with that when we were labeling this,
28:41
you know, the right ovary. It's been mistaken for
28:44
appendicitis because it looks like a tubular blind and structure. It
28:47
has been called ovarian torsion. So you
28:50
just have to have a high index of suspicion that this entity exists
28:53
to be able to think about this diagnosis when
28:56
it doesn't quite fit with a classic, you know ovarian type
28:59
of picture.
29:02
All right, our next patient 21 years old coming in with three
29:05
weeks of abdominal pain.
29:07
And so our findings here, we have an ovary that looks like it's gonna
29:10
be maybe a little bit larger than normal. But you know
29:13
kind of top normal we have lots of peripheralized follicles
29:16
that are all small, but they don't have that sort of echogenic Rim
29:19
right around them. And then we have some complex
29:22
free fluid right next to it with some citations into
29:25
it.
29:28
Putting on some color Doppler flow here. We're seeing a whole lot of vascularity this
29:31
over right here. This is a vascular material here
29:34
a lot of vascular ovary swing over to the left
29:37
side. This is labeled left over that. I'll tell you that we don't
29:40
see the left over in this particular view. This is a bit of the
29:43
uterus and demetrium and then we have this elongated structure right
29:46
here in the midline. And certainly question. Is this just a
29:49
bowel Loop swinging biode argue. We have one back here. This is
29:52
the
29:53
This are also surface use some internal contents right
29:56
here. This doesn't really look the same as that structure
29:59
back here. So when we were able to use some
30:02
cine Clips to figure out, where is this going? What is
30:05
it leading to or towards? What does it connecting it connected
30:08
to the ovary into the uterus. So we thought this
30:11
is a thickened tube. Not anacoex.
30:14
This is not a hydrosal thing. This has some internal echogenicity.
30:17
So that's gonna make this most likely putting
30:20
everything together a PID or
30:23
pelvic inflammatory disease. We had a right over that
30:26
was a little bit enlarged very vascular and
30:29
heterogeneous fluid next to it. So that's
30:32
going to make that an oophritis and a salpingitis on
30:35
the left side this person on exam did end up having mild
30:38
purulent discharge red and cervix tenderness in
30:41
both the next and then tested positive for chlamydia.
30:44
So I'm gonna dive into this a little bit more because PID is
30:47
a spectrum and it's important to keep that in mind. So we
30:50
just saw a southpangitis in an oophritis. Now, we're
30:53
going to look at a tubo Varian complex. So this is different than
30:56
a tubal ovarian abscess. So here we have a picture
30:59
of a right ovary. And without these calipers on it. I would argue be
31:02
hard to say exactly where this ovary starts and ends. It's sort
31:05
of Blends into the uterus nearby. We've lost those crisp margins
31:08
except maybe out here some Chris Martin's over here
31:11
harder to see right sort of distorted.
31:14
Here is in the inexa right adjacent to the
31:17
over. We then have this heterogeneous almost mass-like appearance.
31:21
Except that it's not in the ovary itself, right? There's a little bit of
31:24
vascularity in the wall of this but nothing really internally. This
31:27
is not a solid Mass. This is a tuba ovarian complex
31:30
of phlegamentous sort of pseudotumor. This is
31:33
a developing infection. So this person of right lower quadrant
31:36
pain had a leukocytosis. It's tachycardic and was positive
31:39
for gonorrhea. This is a tub ovarian complex if left
31:42
untreated this will eventually devolve into
31:45
an abscess, but at this point is just a complex.
31:48
This is not drainable and that's what's important about it as well. Not drainable.
31:53
As opposed to the abscess itself. So this is a transominal image
31:56
because you certainly didn't need a trans vaginal in this
31:59
case, but you can see this very thick wall right here some vascularity
32:02
of the wall and again very internally complex,
32:05
but no color Doppler flow in this this is an
32:08
abscess. It's gone past the complex is now an abscess and
32:11
was drained successfully percutaneously.
32:15
So let's go over this because I said it's a spectrum right? So public
32:18
inflammatory disease. It's a spectrum from an
32:21
ascending genital tract infection.
32:25
Symptoms include fever vaginal discharge dyspheriania elevated
32:28
white blood cell count vague constitutional symptoms
32:31
and imaging findings depend on what's being
32:34
affected. You could see some of them
32:37
you could see more than one you might only see one so things to
32:40
keep in mind. So here we have in this particular
32:43
image. We have an ovary tucked in here a
32:46
lot. It's a small follicles all of this complex stuff around the
32:49
over again. We've sort of lost the margins of it again, maybe a
32:52
little bit of free fluid over here. I thought this was going to be
32:55
initially just some complex you maybe some blood
32:58
clots sitting in some fluid right there.
33:01
So when we talked about salpingitis, that's the most account most
33:04
common acute form that we're going to see as
33:07
Radiologists. And what happens is you get edema secondary to
33:10
the infection and that's
33:13
going to cause congestion and increased vascularity.
33:16
The tube itself is then going to start filling with
33:19
pus and that pus is going to spill into the peritoneum causing
33:22
a peritonitis. So this is the same patient where I thought
33:25
that was, you know, hemoradic material makes blood clot something like that turned on
33:28
color Doppler and you can see extraordinary vascularity. That
33:31
was not clot. It would be a vascular. These
33:34
are not bowel Loops. So I thought you know, this is probably some sort of
33:37
inflamed tube at least back here and this
33:40
is a PID type of appearance and maybe we have, you know,
33:43
two ovarian complex starting to form. We've lost the more phalogy of
33:46
the ovary unclear at that point, but that's what we're starting to
33:49
see the peritonitis you may not see that on ultrasound. In
33:52
fact, you probably won't see it, but the patient's going
33:55
to present with the parent tinnitus.
33:57
So after that happened, it's spilling plus into the parrot's name
34:00
the fimbria of the tube start to adhere to the ovary
34:03
and that's when you get the of the oauthoritis and
34:06
then you can start to develop that two ovarian complex. So The
34:09
Oaf right is the ovary starts to enlarge it can
34:12
then mimic other appearances. It almost looks like a tourist ovary
34:15
because it can get bigger because it's reacting to all this
34:18
inflammation.
34:19
And then you start getting destruction you get that tuba ovarian complex.
34:22
So again enlarges hyperemia to the
34:25
ovary peripheralize follicles really does look like a
34:28
torsion case after this
34:31
point the tube eventually obstructs. You can get a Pio
34:34
salping. So at that point where it's not going to be emptying out anymore, so it's
34:37
actually going to fill up.
34:39
And then that's when it can progress to abscess you get that complex cystic
34:42
solid mass and you get the disruption of
34:45
the ad next little architecture and that's really when you start
34:48
really need to think of a pelvic inflammatory disease this
34:51
disruption of a nexal architecture whenever I see
34:54
that and I'm like I cannot figure out what I'm looking at. What is this structure
34:57
where the borders there's two things I think of it's public
35:00
inflammatory disease and endometriosis and those should present
35:03
very differently. But if you're not sure you
35:06
can always give the differential diagnosis and the clinical exam.
35:11
All right. So with that our next patient 29 years old comes
35:14
the Ed for abdominal pain and renal colic. I
35:17
put in quotes the CT which I won't show you showed an abnormal left
35:20
at Nexa and this is our corresponding ultrasound
35:23
image.
35:24
So you can see here. The ovary is going to be very big don't have
35:28
a volume but it's going to be big right but this does not look
35:31
like the same morphology that we saw in the tourist ovary.
35:34
Right? This looks very different instead. We have
35:37
multiple structures forming the over here inside
35:40
the ovary right here with low level internal homogeneous
35:43
Echoes, right? We have increased through
35:46
transmission. So these aren't all solid masses. There's no shadowing
35:49
behind them, except, you know, some Edge shadowing, which is normal.
35:54
But you're getting increased through transmission behind them. So these are fluid-filled processes,
35:57
right? You have a follicle over here, maybe some normal
36:00
ovarian tissue here, but this is a classic appearance for
36:03
endometriomas in an ovary and you could say this shouldn't
36:06
present this way. But in this
36:09
particular patient see also as we swung a little bit more laterally this
36:12
was a pair of tubal cyst here, but we can see the free fluid
36:15
that's conforming to the spaces pushing bowel way behind
36:18
it low level internal Echoes. So this
36:21
is not just free fluid. This is hemorrhagic fluid
36:24
right here. So occasionally endometriosis can present
36:27
in the acute setting so that's what this looked like.
36:31
And that's what this ended up being when she went to surgery, you
36:34
know as elective as an outpatient. This was endometriosis.
36:38
So here's another image from a different patient who presented
36:41
similarly. This is uterus. She had lots of fibers. That's
36:44
why it looks so heterogeneous here, but this was labeled right
36:47
over and I don't see the margins here and I can see
36:50
something over here, but it looks adhesive looks in the wrong spot being
36:53
behind, you know, the lower uterine segment doesn't seem normal and
36:56
then you have this sort of ill-defined tethering structure right
36:59
here. What the heck is that? And so again,
37:02
the clues are all there in retrospect the things that distort architecture
37:05
because of adhesions pelvic inflammatory disease
37:08
endometriosis. So in this case, you could
37:11
attempt some slide Maneuvers if
37:14
your sonographers are familiar with that instead of trying to
37:17
push things apart like we did in that hemorrhagic cyst case, what
37:20
you're trying to do is have two structures slide upon one another
37:23
if they are adhesive together, they will slide together
37:26
if they are separate structures,
37:29
they'll slide against one another normally and
37:32
so we didn't do that in this case. But my best guess is
37:35
this ovary was adhes to this uterus and
37:38
and these are probably either adhesions or endometriosis.
37:43
Affecting the bowel and adhesing it to that.
37:47
This was the left ovary and again without labels where the heck
37:50
is the left ovary, but it's going to be in here somewhere. These
37:53
are some follicles right here. So ovary, you know somewhere around here part of
37:56
the uterus again lots of fibroids and then it's very hard to
37:59
separate it from the bowel right here as well. So these are all adhesions due
38:02
to endometriosis in this particular case.
38:05
Patient did go on to get an MRI not in the
38:08
emergent setting and again, you can see her uterus enlarge multiple
38:11
large fibroids just ignore those for now. This is not talking about the
38:14
fibroids. But this is our T2 image and you
38:17
can see there's lots of free fluid which can be a physiologic finding
38:20
in the young patient except that there's all of these citations in
38:23
it, right? These are all adhesions. That's not normal
38:26
because if you have physiologic free fluid, it's free
38:29
fluid. It absorbs and then next cycle it might happen again,
38:32
but you don't get all of these adhesions. This is abnormal swing
38:35
over to this side. And this is our T1 weighted image and
38:38
you can see this isn't just simple free fluid. This is intrinsically tea
38:41
one dark or sorry bright that's not
38:44
normal either and when you're thinking endometriosis you
38:47
see adhesions right here. This is
38:50
actually hemorrhagic free fluid secondary to it. And
38:53
so that is why she presented acutely is because
38:56
an endometrioma probably somewhere blood acutely
38:59
and that's what we're getting right here. And it's probably
39:02
happen more than once given all of these adhesions right here.
39:07
Um on our particular protocol for MRI of the pelvis the
39:10
female pelvis, we usually get a coronal sequence just to look at
39:13
the kidneys and in the case of endometriosis, you really want to see if
39:16
there's hydronephrosis. But incidentally we saw when we
39:19
were looking this right here. So she's a very large
39:22
right plural Fusion pushing her liver down how
39:25
big the effusion was. So at that
39:28
point too, even though we couldn't see it. We suspected that there was going to be plural involvement
39:31
of her endometriosis to have such a large right
39:34
plural effusion in the setting of everything else going on
39:37
and that's what she ended up having surgically.
39:40
So endometriosis again. We normally think of
39:43
this as chronic pain dyspareunia patients
39:46
presenting with infertility, but occasionally they can present
39:49
acutely.
39:50
Usually it's going to be ruptured from an endometrioma and
39:53
that can cause severe pain you might
39:56
they might instead present due to the complications, you
39:59
know, they might get a hemoparitanium which can cause an inflammatory reaction
40:02
in the peritoneum and they present with the peritonitis instead or
40:05
it can be site-dependent. Right? If you have thoracic involvement,
40:08
you can present due to shortness of breath because of a
40:11
very large plural Fusion like our patient had or they can result
40:14
with the new metaphorax because of their endometriosis, you know
40:17
bowel problems. They could have diarrhea constipation and the rare
40:20
into susception or perforation they can
40:23
present that way.
40:24
This here's an example of endometriuma, which
40:28
is slightly a typical and that has got a layering fluid fluid level.
40:31
So this one bled at some point.
40:35
Okay, so moving on to our last topic, which is
40:38
the uterus. We're going to start with a 24 year old came into the
40:41
Ed with left lower quadrant pain and here's a representative CT
40:44
axial image post contrast through
40:47
here. So I'll tell you this is her uterus over here trying to
40:50
orient you a little bit and with left lower quadrant
40:53
pain. We saw some inflammation in the fat right here around this
40:56
structure.
40:58
So the person who read this, you know said this is a differential case.
41:01
This could be an acutely hemorrhagic cyst. This could be a torched
41:04
ovary. It could be you know PID could
41:07
this be an abscess? This could be an ovarian
41:10
Mass can exclude that recommended an ultrasound.
41:13
So we get the ultrasound and this is all we see in
41:16
the left at Nexa it's labeled left over because we did not see a
41:19
left ovary or any normal left. Ovary. All we
41:22
saw is this solid heterogeneous Mass like structure and
41:25
when you put these things together, there's not a whole lot
41:28
you can do with if you're just looking at the ultrasound but that's CT was
41:31
there so when I was reading this ultrasound, I went back to the CT
41:34
to see if I could figure this out because it didn't really
41:37
seem to match. It's not a hemorrhagic cyst. It's almost looks
41:40
Mass like but the CT didn't necessarily look like that. So going
41:43
back to the CT we figured out that
41:46
this was most likely going to be a fibroid and we did that because putting houndsfield
41:49
units on this collection. It's not an abscess. It's 45. This
41:52
is way too high of a hounds field units to be an abscess
41:55
and not really heterogeneous enough
41:58
to be a flagman. It's process and also
42:01
in retrospects, you could follow the ovarian veins
42:04
and this is actually the leftover tucked in over here and
42:07
there's a little follicle to prove it. We could not find that
42:10
normal ovary during the ultrasound but you could
42:13
on CT if you were looking specifically for it that then
42:16
changed everything right because this structure is
42:19
therefore not the over it's not a hemorrhagicist. It's not an ovarian
42:22
mass. And so if you go back to the
42:25
ultrasound and thinking what does this look like
42:28
if this was placed somewhere else? Let's say in the uterus. What
42:31
would I think that is and I would say well, you know that looks like a pretty classic fibroid.
42:35
So then going back again to the CT here.
42:38
That's where the inflammation is. This is the same structure. It's
42:41
the same size. This is a claw sign from the uterus. And I
42:44
said, you know what? I think this is all just an ischemic fibroid and
42:47
that's why she's presenting acutely. This is not an ovarian problem.
42:50
She does not need surgery pain medication and a
42:53
little bit of time.
42:55
And so they discharged her home and she did. Okay, she did end up coming in
42:58
for an MRI just to prove.
43:00
And that's what the result actually was and so here is
43:03
a T2 image uterus over here has a few
43:06
fibroids have some free fluid and you see this T2 dark
43:09
ring around the fiber right here, very
43:12
heterogeneous internal signal and here are her pre
43:15
and post contrasts. So again intrinsically T1, bright
43:18
that is because this Hemorrhage right? So there's blood in the
43:21
structure and absolutely no internal antenna enhancement
43:24
whatsoever. This was an ischemic fiber at this
43:27
point. The fibroid was, you know, essentially dead at this point, but
43:30
when they acutely bleed and when they acutely infarct, it
43:33
can be a quite painful process so they can come
43:36
to the Edie this way.
43:38
Here's a different example of a degenerating fibroid. This
43:41
one only got an ultrasound. She was
43:44
36 year old came in with heavy vaginal bleeding and pelvic
43:47
pain. She told her sonographer that she had a
43:50
history of necrotic fibroid and a C-section but we didn't know when
43:53
you know was that remote diagnosis was one of them more recent or
43:56
both of them were recent no additional information. So here's
43:59
our sagittal uterus picture and we see all of these echogenic Foci.
44:02
It looks like it's an endometrium. You know, that's a
44:05
little bit of enemy Trill tissue right there and you have all the dirty shadowing right
44:08
here. So we're concerned for air.
44:11
Here's our transverse picture again more echogenic Foci dirty
44:14
Shadow and kind of confirms that and so the first thing you
44:17
think about when you see air in the endometrium is endometritis, especially with
44:20
the history of C-section. We called upstairs. It turns out her C-section
44:23
was several years before she has not recently had instrumentation.
44:26
She is not acting infected no
44:29
fever white count elevation anything like that. And
44:32
so we kind of went back to this after finding out that information and you
44:35
can see this is almost you know, Mass like the air
44:38
is conforming to this structure. It's not conforming to
44:41
the endometrium which is out here. It's conforming to an internal
44:44
structure right here. And so then given the history
44:47
than the chronic fibroid we said, you know what that's probably what this
44:50
is. This is a necrotic library that is in the endometrial
44:53
canal.
44:54
Now I don't have any follow-up Imaging for this but she did have notes in
44:57
the that she had an outside CT later
45:00
on that did show a necrotic fibroid that
45:03
was treated with a myomectomy in a non-acute setting.
45:06
So that's what this was.
45:08
So to briefly review degenerating fibroids hybrids
45:11
can degenerate multiple different ways, you know
45:14
can be cystic red. Mixoid and MRI can
45:17
usually differentiate those if you needed it for any reason, but it
45:20
is a mimicker and it can be a challenging ultrasound diagnosis
45:23
on its own so
45:26
Um, it's something just to keep in mind and I personally think
45:29
you'll probably need a seat to your MRI to help figure it out
45:32
oftentimes, but these occurious which
45:35
is the red one is a hemorrhagic infarction due to
45:38
obstructing draining veins most commonly if it's going to happen is during
45:41
pregnancy or with oral contraceptive use and
45:44
can present as an acute abdomen.
45:47
Yes, and a fibroid that can be due to necrosis or
45:50
due to post treatment uterine artery embolization. That's normal
45:53
finding there. It's honestly very very rarely and
45:56
infection.
45:59
Right next case 29 year olds, six months of vaginal bleeding
46:02
and one week of worsening pelvic pain rule out
46:05
torsion.
46:06
So in this case right here, we have something labeled lower
46:09
uterine segment. They were not able to get the entirety of
46:12
the uterus. So it wasn't clear. It was a small uterus
46:15
was this something else that was going on. So he put
46:18
some color Doppler or power doppler on and you can see this is
46:21
very vascular. This is not a normal appearance of a uterus right
46:24
here. So the sonographer is like I can't figure out what's going on. I can't even
46:27
see an endometrium is this all endometrium but then
46:30
the uterus would be very small didn't they make a whole lot of sense? So went
46:33
back and did a trans abdominal try and figure out what's
46:36
going on and here you can see we have the funnest of
46:39
the uterus. We have a normal endometrium. This does not match with
46:42
what we saw on the transvaginal and that
46:45
is because this structure down here is separate from
46:48
this structure right here. We're not the same. This is normal. This is
46:51
abnormal. So in that case we could diagnose we have
46:54
vascular mass in the lower you're in segment or cervix and this is
46:57
most likely going to be a cervical only and see later proved on
47:00
MRI and biopsy as well. So
47:03
this, you know T2 mildly bright Les.
47:06
Invading the bladder a bit right here. This was a cervical cancer that
47:09
presented in the Ed.
47:13
Okay, so let's talk very quickly about this. This is usually an
47:16
outpatient presentation, but occasionally they'll come in in the
47:19
emergency setting usually due to vaginal bleeding or signs of
47:22
anemia rarely from ascites sometimes from renal failure
47:25
type symptoms, but they're most commonly going to come in with vaginal bleeding
47:28
or discharge. They may have obstructive symptoms. But usually
47:31
the hydronephrosis is a slow process, so
47:34
it's silent. So if anything they might come in because a renal
47:37
failure issues
47:39
But if they do get ultrasound imaging if
47:42
you can see the cancer, which you can't always but
47:45
if you can it will look Mass like it will most commonly
47:48
be hypokovic and heterogeneous.
47:50
Centered in the cervix are lower uterine segment. Although
47:53
it certainly can grow up. And usually they're going to be vascular not
47:56
always but usually they're going to be vascular like this case was
48:00
other secondary things that you can look for that
48:03
may help people would have an enlarged uterus like we did in our
48:06
case.
48:07
And you kind of hydronephrosis. So if you can look at those kidneys
48:10
see what's going on here most common cause or one of
48:13
the most common cause of bilateral hydronephrosis and a female patient is
48:16
going to be cervical cancer. So it's worthwhile looking with your
48:20
ultrasound if you have it still available if you're checking these
48:23
exams real time.
48:25
Okay, next patient 30 year old history low
48:28
transverse C-section six days
48:31
prior to presentation coming in with fever and fast-melling discharge.
48:34
This is her ultrasound picture, which is where they started. It's not
48:37
a great picture. The uterus is sort of in a straight
48:40
back configuration really hard to see much of what's going on here. But if
48:43
you take your time and look there's information here that
48:46
you can use and I would say the endometrium is
48:49
going to be somewhere around here and we have echogenic focine here, right? I'm worried
48:52
about air. She did just have a C-section but I am worried about the air
48:55
special given the history and then following it here. This
48:58
is where I'd expect the sea section scar to be right right in the lower
49:01
uterine segment. If this is sort of the funest way out here that's not
49:04
normal that I can see air going into it.
49:06
Flip over to the transverse images right here again air
49:09
in the endometrium down here.
49:11
And now we see air sort of spilling next to the
49:14
uterus right here. This looks like it's outside of the uterus.
49:17
So we're going to play this cineclip right here. Which again it's terrible terrible
49:20
quality really hard to see much of anything in this uterus given the
49:23
positioning of the patient. But once we get through the city, you're
49:26
gonna find where the endometrium is. We're going to follow this up right
49:29
here and you're gonna watch all of that gas just spilling out
49:32
into a collection nearby.
49:34
So she went on to get a seat CT next and you can see
49:37
everything. That's actually it was there on the ultrasound you have
49:40
an enlarged uterus to air within the endometrial Canal you
49:43
have air here through the C-section which is not close.
49:46
This is dehist and then that spills out
49:49
into this gas collection around the uterus right
49:52
here right blades down here. This collection has Aaron. This is
49:55
all what we could see an ultrasound if you still looked and didn't just give up
49:58
and say this is non-diagnostic and then the trans abdominal
50:01
Imaging wasn't useful at all. And that is because she actually
50:04
eviscerated her small bowel through the
50:07
C-section here, right the whole thing to his small bowel obiscerated.
50:10
This isn't our case. She went to the or just a
50:13
few hours later.
50:15
And they found an endometritis and a
50:18
C-section to his sense.
50:20
So endometritis. This is the most common cause
50:23
of femur fever and the postoperative post-pregnancy
50:26
patient, especially within the first 24 hours. It
50:29
is more common after C-sections than it is after spontaneous
50:32
vaginal delivery, but certainly can occur in
50:35
both. It is important to note. This is a clinical diagnosis.
50:38
It is not a radiology diagnosis. They are
50:42
going to treat the patient with broad spectrum antibiotics, but what we need to
50:45
tell them is there any other complicating factor that they need to
50:48
also account for or potentially do something about such as
50:51
retain press conception in fact that hematoma or an
50:54
abscess.
50:55
So appearance there's an
50:58
overlap with normal postpartum physiologic findings. You
51:01
can have a normal ultrasound. But if you are going to see something we're
51:04
looking for echogenic materials such as hematoma, which
51:07
again is a normal post-op or post a post-birth finding
51:10
and you're going to look for air remembering too that if
51:13
they had a C-section air can be present for a few weeks after a c-section
51:16
be totally normal. So it's clinical correlation. Just
51:19
keep that in mind.
51:21
Right next case 21 year old medically induced abortion
51:24
two weeks prior coming in with significant bleeding. Here's our
51:27
uterus Imaging we have a thickened heterogeneous endometrium
51:30
right here. Is that just some blood clot. We know she's bleeding a
51:33
lot throw on some color Doppler and you can see no, this is
51:36
not a vascular clot or hemorrhagic material.
51:39
This is super vascular and given that provided history. We
51:42
can see it connecting to the myometrium right here. This is going to
51:45
be retained products of conception.
51:48
So retain products and conception are residual tissue after
51:51
delivery a miscarriage or termination. They are
51:54
usually heterogeneously echogenic not always
51:57
but that's the commonest and the important distinction is
52:00
that it is in the endometrial Canal color Doppler is
52:03
going to help you. Most of these are vascular around 70
52:06
to 80% Although not all of them are so because
52:09
of that there is a significant false positive rate because we can
52:12
always tell here's another example of one where you
52:15
can see abnormal color flow in the endometrial Canal.
52:18
There's heterogeneous the ecogen tissue. This was a retained
52:21
products of conception.
52:22
And I would like to touch briefly on enhanced my
52:25
Mutual vascularity because this is sort
52:28
of like a spectrum. This is a sub-involution of
52:31
the placental site previously. These were all called avms and
52:34
what it is or what we see is increased blood
52:37
flow in the myometrium after birth to these specific
52:40
areas. So this is actually the same case that I just showed you but we're in
52:43
transverse now and so it's important to note that EMV
52:46
may be transient so you don't
52:49
necessarily have to treat them but they can overlap with retain press
52:52
of conception, which is what this was. So the last part I showed
52:55
you where the internal and a mutual components are
52:58
vascular and this part this is all in the myometrium all
53:01
of this vascularity here in the serpentine structure right here. So
53:04
this is a patient who had EMV and retained
53:07
products of conception.
53:09
And this is an example of one who just had an EMD. It's only
53:12
in the myometrium. So you're looking for Cystic or tubular anecost
53:15
structures. If you do spectral Doppler Gall, very
53:18
high peak velocities low resistant waveforms. If
53:21
you're interested in learning more about these spectrums. I had
53:24
encourage you to visit my master course on MRI online of the uterus
53:27
where we get into a little bit more depth
53:29
with ease
53:32
and then the last part of the spectrum is your postpartum. This
53:35
patient had postpartum endometritis retain products intervene on
53:39
twice. This was her Imaging from guy. They did not put colored up or
53:42
flow and unfortunately, but came back to us with vaginal bleeding and so
53:45
in this case looks similar to last that I showed
53:48
you but we have this nidus right here.
53:50
And colored Doppler that thing fills right?
53:53
So this looks like it's going to be an AVM.
53:56
So this is a vascular malformation different than an EMV.
54:00
Here is a cine Cliff of the same patient. This is
54:03
going to be a contrast ultrasound you're going to watch the structure and
54:06
see right here start to feel early and we
54:09
did this because this person was going to be treated. She was bleeding so heavily and
54:12
they needed to know that she didn't also have retained products of
54:15
conception left because if they embolize that
54:18
they can get septic so we were able to show all those internal
54:21
components in here. None
54:24
of that enhance. That was just blood no
54:27
retained products. It's just the AVM right there.
54:31
And so these are rare they can be congenital. They can be acquired and
54:34
what you're looking for is hypochoic. But a myometrial component
54:37
to this it may Pooch into the endometrium like
54:40
ours did but it's going to be myomatrial based you're gonna
54:43
torturous tangle vessels low resistant waveforms and
54:46
you're going to have elevated Peak systolic flow.
54:50
And here was when they got embolized you can see the AVM
54:53
right there and the tangle of blood flow.
54:57
Okay, and very very quickly. This was the put it all together case. This
55:00
is a 44 year old with heavy vaginal bleeding. We have a structure
55:03
in the left ovary here with what we learned looks
55:06
like it's going to be an endometrioma low level internal Echoes increase
55:09
through transmission very little normal ovarian tissue,
55:12
except there's some blood flow in it. So, you know, is this
55:15
something else? Should we be thinking to blueberry and complex?
55:18
We're looking at the right next so we see this, you know weird structure right
55:21
here hard to tell what's going on there as well. Is this a dilated fallopian tube?
55:24
Oh, maybe we have a salpingitis. There's a lot
55:27
of vascularity going on right here, right? What's going on right
55:30
here? How do we put all this together? The uterus also doesn't look
55:33
normal. Is it you know, is there a mass behind it is their
55:36
Mass involving it really challenging, you know,
55:39
give a differential to this type of case she ended up having palpable
55:42
findings elsewhere eventually got a PET CT and this ended up
55:45
being malignancy. This was a burkus lymphoma. So even though we did
55:48
our best we went through our differential diagnosis endometrium to
55:51
ovarian complex PID other masses. Sometimes you
55:54
just can't know you won't always be right in this
55:57
case. That was our put it all together case of a different
56:00
malignancy.
56:02
Outpatient presentation can show up
56:05
with vaginal bleeding tense societies. This was a mucinous tumor right
56:08
here that can cause a lot of abdominal pain as well. And
56:11
so with that this is a list of my references. I
56:14
know there are a lot on there but there are a lot of good things to read to
56:17
go over these.
56:19
And so with that I will end and answer any question. Do you
56:22
guys might have
56:26
Okay, so pulling open
56:30
the Q&A. Let me look over here. So what are the size criteria for
56:33
Volver clitoral vaginal varices? What are the causes other than
56:36
public Congestion Syndrome quick question. So there's not really a
56:39
size criteria necessarily for this it's going to really be
56:42
a clinical type of thing so they can be very small
56:45
varices like those were pretty small but she had
56:48
significant symptoms that were thought to be related to them. So they
56:51
ended up embolizing and treating them. So it's really going to be a clinical put
56:54
it together picture. Normally you don't see the vessels in
56:57
the vulver area. So the fact that you're seeing them already makes
57:00
them a bit abnormal and then they have to clinically put them together pelvic
57:03
congestion syndrome. Like you said that reflex is
57:06
going to be a cause of it and then pregnancy itself and it's it's the hormones
57:09
that go along with it. Those are the most common ones.
57:13
All right how to differentiate ovarian torsion versus torso, very malignant
57:16
tumor. That one's a tricky one. You can
57:19
look for something that looks Mass like in that ovary. But
57:22
sometimes you just can't tell if that ovary has
57:25
necrosis enough. You might not be able to tell and you
57:28
just have to leave it as a differential diagnosis because that malignant
57:31
tumor can cause a lead point A lot of times too.
57:34
It's going to be helpful knowing just the age range of the patient. So if it's
57:37
a younger patient, probably not going to be malignant and
57:40
so you can kind of go with the probability of it unless it's going
57:43
to be something like a dermoid and then hopefully you'll see those echogenic fat
57:46
or something like that to go with it. So it's
57:49
gonna change depending on the age of the patient is how I
57:52
help decide that and then there's going to be something that
57:55
looks sort of mass like and then you just have to know sometimes you're just not
57:58
going to necessarily be right, but that's my best advice there.
58:03
Um, okay any experience with vulvodynia do to myofascial pain
58:06
syndrome? Unfortunately, I do not have any
58:09
expertise in that so I'm not going to comment on
58:12
that any further apologies for that.
58:14
Okay, what is the importance of the ovarian artery?
58:17
So the artery itself? We're not usually necessarily going
58:20
to see that and evaluate the artery itself. It's going
58:23
to be so small on a transvaginal ultrasound. It's just very
58:26
tricky to see it or find it or be confident about that. We're really
58:29
looking at sort of the arterial supply to
58:32
the ovary itself. So it's the vein because
58:35
the vein is more compressible. That's what's going
58:38
to compromise first in the ovary and cause this
58:41
whole Cascade of symptoms that go along with torsion the ischemia
58:44
when the artery starts to get affected that's usually
58:47
the arteries within the over itself and not the ovarian order
58:50
itself. That's the problem because that would later
58:53
come last. So the importance of the artery itself is
58:56
a little bit less. It's the vein that starts the Cascade of
58:59
problems that the patient presents with intuition.
59:02
Criteria for operators great question. There
59:05
are not specific criteria for that.
59:08
So you you're going to have to use your best judgment for
59:11
those knowing that your sonographer is can of
59:14
course, you know change the settings a little bit to look like there's a lot of
59:17
Doppler flow to an ovary more than you're used to seeing but other
59:20
things I'm going to look for if I think that there's a lot of blood flow
59:23
there is I'm gonna look at the size of the ovary. If you
59:26
have an oopharyus that ovary has to be enlarged and you don't have
59:29
another reason for it meaning there's not a hemoradic system a
59:32
giant dominant follicle something like that to account
59:35
for the size. So that's when I start thinking we have an enlarged
59:38
ovary. They're not presenting like a torsion and
59:41
usually if you have an oafaratus, there's going to be something else going
59:44
on like the complex free fluid around it, right because that plus has
59:47
to spill all the tube kind of bathe the
59:51
ovary in it and that's when it gets the itis. So you're
59:54
gonna look for that prevalent material low level
59:57
internal Echoes of free fluid around it. The ovary
60:00
is gonna enlarge and have that abnormal more biology.
60:02
Looks like a torsion except they're presenting differently.
60:05
So that's how I would diagnose an othritis. It's
60:08
going to be based off of morphology and what the ovary looks like and then
60:11
the color Doppler flow to me is just what kind of
60:14
helps seal the deal that does look elevated. It does
60:17
look asymmetric to the other side. I think this is an oafaratus and
60:20
then they can do the property the proper testing.
60:23
Okay, comparitoneal inclusions this lead to any acute complications
60:26
seen on ultrasound.
60:29
Not in my experience. It hasn't it tends to be more of
60:32
a chronic problem than an acute problem because everything's
60:35
kind of contained in those adhesions and then because
60:38
it is free fluid things can sort of move around the bowel kind
60:41
of Squish next to it. You know, it won't necessarily ever obstruct
60:44
it so Norma it's going to
60:47
be chronic type of bulk symptoms whether you know, they have constipation or
60:50
belly fullness things like that where people need to get a treatment
60:53
for the peritoneal inclusion cyst and then knowing too that
60:56
they often just recur, but if you're having those kind of chronic symptoms when
60:59
they tend to treat them
61:01
Okay can endometriosis mimic PID and how absolutely
61:04
it absolutely can a specifically
61:07
on Imaging appearance. They can they can
61:10
mimic one another especially if you don't have the endometrioma or
61:13
classic endometrioma to help you figure that out. But the
61:16
appearances are going to be similar you can lose that like
61:19
sort of architectural Distortion where you can see all the borders of
61:22
things. That's how it mimics PID and then
61:25
the low level internal Echoes In The Free fluid that
61:28
can be pus that can be blood in the
61:31
salpingitis that can be blood from endometriosis or
61:34
that can be pus from a PID a lot
61:37
of overlap there. But clinically they should be different and
61:40
that's how the clinician can tell them apart because they should have
61:43
fever white count and if they're not sure they can do that by manual exam
61:46
look for purulent fluid coming from the cervix to
61:49
test and if you're still not sure for whatever reason you
61:52
could get a pelvic MRI and that should help tell you as well.
61:56
Okay, most the time you're showing transvaginal ultrasound pictures. This is okay
61:59
in your setting most women refuse it and using a
62:02
lot of trans abdominal ultrasound. Sure. So transvaginal is
62:05
going to be much more sensitive than trans abdominal because
62:08
you have that high frequency Imaging the best chance
62:11
you have if people are refusing to have it which is certainly
62:14
within anyone's right to not have that is to
62:17
have the full bladder. That's really the best you can do. I found
62:20
sometimes they can fill a bladder almost too much and it pushes,
62:23
you know, the uterus or the ovaries too far
62:26
away and you almost can't see them. So you want sort of a happy medium, but
62:29
you'd rather have it more full than less and that's
62:32
gonna help you some of the things you just won't be able to do like if
62:35
you're trying to push things apart to separate you on
62:38
ovary versus, you know, something adjacent to the over doing slide Maneuvers,
62:41
you're not going to be able to do that with just trans abdominal
62:44
but again feeling that bladder is
62:47
the best chance you have of looking for the more followy of all these different
62:50
structures getting your spectral Doppler waveforms so that
62:53
you can make a lot of these diagnoses confident.
62:57
Okay, what was the diagnosis in the second case? I apologize. I'm
63:00
not sure what the second case was going all the way
63:03
back but it should be a companion case to
63:06
whatever it was that I showed before so that that
63:09
should be a whatever it was and whatever section.
63:12
Okay, tethered uterus any better terms for
63:15
this please.
63:16
I haven't found it's really adhesions. I really
63:19
would all of these things are but sometimes the it's the
63:22
endometriosis itself. That's sort of tethering the uterus
63:25
to a different structure right there. It'll be like a deep infiltrating
63:28
endometriosis. So depending on where it's
63:31
coming from they in endometriosis. They do have different terms.
63:34
So I don't want to you know, I as a
63:37
catch-all term I use that it's tethered but you could
63:40
use adhes just as easily or if there you can see an endometriosis
63:43
deposit. It might be because of
63:46
the deposit self and those have different needs depending where they're coming
63:49
from. So I think you just have to refer to those tethering I
63:52
use as a general overall catch all type of term.
63:56
Diameter criteria for an enlarged ovarian vein
63:59
that I don't have I don't know
64:02
if there is a normal one if it's going to change based off
64:05
of Union menstrual period your fluid intake how
64:08
hydrated you are so I don't have a normal diameter for
64:11
that unfortunately.
64:13
Third case complicated Bartholin gland cyst
64:16
with what contents was infected that I don't honestly know.
64:19
I think they just treated it empirically and the patient got better.
64:22
I don't think they ever didn't aspiration. So if they weren't getting
64:25
better and aspiration of that Bartholin glandsis would certainly help
64:28
to guide treatment, but I believe they just treated it empirically it
64:31
got better. So that was that
64:34
How can we differentiate endometrioma from hemorrhagic cyst
64:37
on a transodominal ultrasound if we don't have free intradominal fluid
64:40
based off of appearance or other diagnostic methods great
64:43
question. So you're going
64:46
to need to use the bladder as a window as best you can and just
64:49
try different angles to get to see it right there. Sometimes you
64:52
can't tell a very acutely hemorrhagic cyst
64:55
can have low level internal Echoes and it looks like an endometrioma and
64:58
you cannot tell so in those cases you just need
65:01
to get a follow-up ultrasound again because the hemorrhagic system
65:04
will resolve and endometrium will not so use the bladder
65:07
as a window you might have to angle across the pelvis a
65:10
little bit to get to it. And if you still can't tell if you
65:13
don't feel like you're getting diagnostic images doing it that way pelvic
65:16
MRI is going to be very sensitive and
65:19
very specific for these entities. So that would be the next best
65:22
thing.
65:24
Right next case over next question ovarian edema
65:27
and hyperstimulation syndromes can also present in
65:30
acute settings great. That's a really great point the key
65:33
to these is that it's going to be bilateral hyperstimulation
65:36
syndrome, whether it's from you know, a molar
65:39
pregnancy or from in vitro fertilization
65:42
type symptoms. Hopefully you
65:45
get that history if it is in vitro and
65:48
if it's a molar pregnancy, you should potentially have
65:51
the positive beta HCG and the findings in the uterus itself,
65:54
but the the key finding there is it's going to be a bilateral
65:57
process. So that's gonna take out torsion because
66:00
it's just exceedingly unlikely to have a bilateral varying.
66:03
So then you're left with a polycystic ovarian
66:06
syndrome versus a hyperstim syndrome and Hyper stem
66:09
syndrome the follicles tend to be a lot larger in a
66:12
p cost type over they tend to be lots of small little follicles
66:15
and still plenty of ovarian stroma. Where's the hyper stems
66:18
you get very little stroma and lots of dominant follicles.
66:21
It's going to be a bilateral process.
66:24
And usually these ovaries are not just a little bit enlarged, you
66:27
know, 50 milliliters or so. They're very enlarged like
66:30
hundred 200 and again bilateral. So
66:33
that's going to help you differentiate between those as best as possible.
66:36
And yes, they can absolutely present an acute settings. They can believe they
66:39
can cause itises peritonitis that type of thing as
66:42
well.
66:43
Okay, how to measure an over when a large cyst is there's our last
66:46
question.
66:48
So the sonographers will measure unless it's you know, pedunculated one
66:51
our sonographers measure the entire over itself including
66:54
the cyst or mass if I want to decide you is
66:57
this ovary enlarged or does the cyst Encompass that I will measure the
67:00
assist itself do a volume calculation and minus those
67:03
volumes to see if the ovaries still normal size or not, but I
67:06
do include the cyst within the ovary as well
67:09
because I think that's also useful that's a mass that the surgeon needs to know
67:12
how big this mass is going to be can help them to prepare how they're
67:15
going to approach their surgery as well. So that's
67:18
what I like to do volume wise if it's completely exophytic
67:21
like the one case I showed and we didn't
67:24
know what it was at that point. I would then I would give it two different
67:27
volumes because they really were almost like two different structures there.
67:30
So that's sort of more the exception in the world will usually have it
67:33
all be one thing.
67:35
Okay, I ran a little bit overboard, but thank you for your questions, and thanks for
67:38
coming everybody and I really appreciate your time and thanks again for
67:41
coming. Thanks again to MRI online as well for having me.
67:45
Watch Magellan. Thank you so much for your lecture today and thanks
67:48
to all for your participation and our new conference a reminder
67:51
that you can access the recording of today's conference and
67:54
all our other previous and conferences by creating a free MRI online
67:57
account.
67:58
Be sure to join us next week on Thursday, December 22nd at
68:01
12 pm eastern time for a lecture from Dr. David
68:04
yousum on conflict resolution.
68:07
You can register for that lecture at MRI online.com and follow
68:10
us on social media for updates on future and conferences. Thanks
68:13
again and have a great day.
Kathryn McGillen, MD
Assistant Professor of Radiology, Medical Director of Ultrasound
Penn State University Milton S Hershey Medical Center
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