adenexal pathology inflammatory dx Flashcards
what is the most common preventable cause of infertility in the US?
PID
what infection occurs bilaterally and can affect the uterus,endometrium, fallopian tubes ovary and broad ligaments?
what are these termed when infected?
PID
Uterus
– Myometrium termed myometritis
– Serosa termed parametritis
Endometrium termed endometritis
Fallopian tubes termed salpingitis
Ovary termed oophoritis
Broad ligaments termed parametritis
~ home man women seek treatment fo rPID / yr
how many become infertile?
1 million
100,000
what are some risk factors/etiologies associated w/ PID?
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)
what are usual cuses for PID?
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
how is PID spread?
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
what are the infection pathways for PID?
what is teh infection spreading?
PID
who is the most susceptible to PID?
“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
wht are some clinical findings associated w/ PID?
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)
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
PID
what type of pathology can be associated w/ PID?
name some.
acute, subacute or chronic
Salpingitis Hydrosalpinx Pyosalpinx
– Parametritis
– Pelvic peritonitis
– Tubo-ovarian abscess (TOA)
– Endometritis
–
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
– Endometriosis
what can repeated episodes of PID cause?
“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
what varies depending on if the pathology is acute, subacute or chronic.
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
what is an inflammation of a fallopian tube?
salpingitis
Note the redness associated with acute inflammation & pus coming out of the fallopian tube
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)
hydrosalpinx – Large amount of fluid in tube
what can happen w/ the fallopian tube in PID?
Pus within an inflamed fallopian tube
Large amount of pus in tube & adhesions (white scar tissue)
what does this look like?
parametritis - Infection within the broad ligament and the
uterine serosa
what is an Inflammation that involves other pelvic
structures like the bowel, bladder, ureter, and adnexa
Pelvic Peritonitis
what infection involves the ovary and fallopian tube?
TOA tubo-ovarian abscess
what is this?
TOA
what does endometrities most ocmmonly occus iwth?
– PID
– Patient in postpartum state ( Due to premature rupture of membranes Long labor Retained products of conception)
– Following instrumentation into the uterus
what is also known as violin string adhesions?
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
what is Fitz-Hugh-Curtis Syndrome (Perihepatitis)?
what % of PID pt does this occur in?
clinical symptoms?
labs?
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”
what does a normal fallopian tube look like.
how about salpingitis?
– 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
what does this look like?
salpingitis - On this TV US it looks like an inhomogeneous
enlarged inflamed ovary
what is this?
hydrosalpinx
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
explain what you see
hydrosalpinx
fluid enhances posteriorly
– The echoes seen in the tube are caused by
artifacts and this is not pus
what is this?
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
what is this?
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
what is a thickened fallopian tube indicative of?
acute dx (hydro or pyosalpinx)
*A fold or scar tissue may be seen within
the tube giving the appearance of a
complex mass
how can you tell the difference b/t bowel and tube?
– 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
what is the measurement for acut inflammation of the fallopian tubE?
what does this thickening resemble?
> 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
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
Hydrosalpinx & Pyosalpinx
what us findings would you expect to find w/ pelvic peritonitis
– 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
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
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
what is this? describe it sonographically.
Fitz-Hugh-Curtis Syndrome (Perihepatitis)
Typical parallel violin string appearance (white
arrowheads) in ascites (anechoic fluid denotes
all of the septations surrounding the uterus
what is this? describe it.
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
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
– 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
_____ – 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
Endometritis
fyi
what is this?
Chronic
– Adhesions
– Note the diagram has
extensive adhesions
matting the entire
pelvis!
____ 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
PID
What is the best differential diagnosis for
this adnexal image?
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
What is the best differential diagnosis for
this adnexal mass?
This is a well well-defined homogeneous mass
with low low-intensity echoes and acoustic enhancement
Best differential is an Endometrioma (chocolate cyst)
What is the best differential diagnosis for this 34 year old with pelvic fullness and pain during her periods?
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
