Intro to US imaging & Pathology Flashcards
what is differential diagnosis based upon?
Symptoms and laboratory results
Sonographic images
what needs to be included when you “present a case” to the doctor? (5)
1) We ‘tell the patient’s story’ when we present the case. Begin with patient history. e.g.‘This is a 25 year old female with acute (versus chronic) pain located…
2) Continue with laboratory and other exams results the patient may have had. e.g ‘She has elevated WBC’s and her pregnancy test is pending results’
3) Then describe each sonographic image using sonographic terminology e.g. ‘This is her TA longitudinal midline image demonstrating a posterior heterogeneous area in the pouch of Douglas. It is not anechoic yet it is fluid filled because it enhances and I think it resembles blood’……
4) Go through each image explaining your thought process
5) Conclude with your list of 2 or 3 differential diagnosis specific for this patient/case
What does the embryo form in a female?
Fallopian tubes
Uterus (ML septum gone by 3rd month)
Upper vagina
What are teh male and female ducts that form genitilia named?
male = mesonephric or wolffian
female = paramesonephric or mullerian
what are the 4 remnants of embryology?
Hymen: Covers external vagina
From urogenital sinus
Gartner’s duct: Runs parallel to uterus inside of broad ligament
Part of mesonephros
Vaginal fornices: Wrap around external os
From Műllerian
Hydatid (of Morgagni): Fallopian tube appendage
From paramesonephric duct
what are a majority of congenital anomalies caused by with regards to genitilia?
what can this type of agenesis or incomplete/improper development involve?
failure of paramesonephric/mullerican duct to develop.
can involve the: Uterus, Cervix, Vagina
*NOTE there are usually only 2 ovaries & 2 fallopian tubes depending on the type of anomaly
Remember that the ovaries develop separately and we will cover those later
what 5 types of mullerian duct congenital anomalies are there?
didelphys, bicornuate, septate, unicornuate, arcuate
what type of mullerian duct anomaly is present in these images? how can you tell?
Uterus Didelphys
Non-Pregnant Longitudinal US Findings consist of:
2 Parasagittal midline uterus images are demonstrated
2 cervices & 2 vaginas (note the two long images appear as a midline image – important to label images (right long, left long)
2 Endometrial stripes/echo complexes
Best seen during secretory phase
hwat mulleridan duct anomaly is present in this image? how can you tell? what are teh dotted oval outlining?
Uterus Didelphys
Non-Pregnant TA US Transverse Findings consists of:
External contour of uterus is helpful to differentiate from a bicornuate uterus. Note how each half is tilted a little differently compared to the other
dotted lines= external surface of each uterine horn
what mullerian duct anomaly is present here? how can you tell? what is the difference b/t the 3 images?
Bicornuate Uterus – Incomplete or improper fusion of the Műllerian ducts results in a heart-shaped external contour
Duplication of uterus and/or cervix varies (Complete or partial) based on the cervical situation due to the ML (mid-line) connection / length
1) rudimentary horn, unicollis
2) 2 cervix (bicollis/complete)
3) 1 cervix (unicollis/partial)
which mullerian duct anomaly has:
Low incidence of fertility complications (the exception is with a rudimentary horn)
- If an embryo implants in the rudimentary cavity, it may grow until about 12-16 weeks when rupture of the uterine cavity occurs
- In many cases of pregnancy, when a gestational sac is present in one horn there is a decidual reaction in the other horn
Pre-term labor is typical
bicornuate utuerus
The _______ uterus has a mid-sagittal indentation of the external fundus of at least 1 centimeter in depth and a muscular uterine connection/fusion
bicornuate
what are the geen arrows pointing to?
endometrium’s
note: TA US transverse of at the uterine body (curved white arrows) Note the slight shadow between the fundus and the angle of the two halves is equal and line up with together
what is notable about this image (TV US Coronal at the uterine body) of a bicornuate uterus?
Note the body is thick and fused where a didelphys would have separate bodies (blue arrow)
The secretory endometrium’s each have posterior enhancement
what is this mullerian duct anomaly called? how did this happen?
Septate Uterus - When the uterine cavity is separated by a septum
It is due to failed degeneration of the median septum
The septum length can vary
Note the septum thickness is thinner than a bicornuate connection
Note the external FUNDAL contour is NORMAL
May have slight indentation less than 1 cm
which mullerian duct anomaly can causethe following?
Implantation on this results in pregnancy loss due to lack of adequate blood supply
keeps implantation from even occurring
can be removed hysteroscopically
Has the highest incidence of spontaneous abortion (up to 67% has been reported) & implantation problems
septate uterus
what anomaly is demonstrated in these images. do they al have an anomaly? any differences?
septate uterus
Fundus may show 2 endometrial echoes that join at the body or cervix
Septum not well seen on 2-D US unless pregnant
There are 2 closely spaced cavities with 1 fundus and sometimes 2 cervical canals or a vaginal septum
The uterine cavity is divided partially (Left image) or completely divided (Right image) by a septum of variable thickness
what anomaly is this? how can you tell?
what do you want to be careful about not confusing it with?
TV US Coronal a sub-septate uterus occurs if reabsorption of the lower part of the median septum occurs, but the top of the septum fails to dissolve. The complete septate uterus may include a septate vagina and/or cervix
Don’t confuse a septum with synechia (scar tissue or adhesions) from a D & C or multiple procedures
what does a unicornuate uterus look like?
hint: This is difficult to differentiate from a normal uterus but is suspected when the uterus appears small and laterally positioned
why does it look this way?
what other organis it associated with?
list 2 of the 3 clinical finidings associated with it.
cigar
only 1 of the mullerian ducts develop
huge association w/ renal anomolies. mesonephric duct has a lot to do w/ kidney development. if mullerian is gone on one side, kidney is most likely gone on same side as well.
Is related to infertility and pregnancy loss
Increased incidence of preterm labor, abnormal fetal presentation, prolonged labor & low birth weight
Associated with renal agenesis on the contralateral side
what congenital anomaly is present here?
what is normal? not normal?
what may cause this in utero? what does it predispose female off-spring to?
arcuate
External shape & size of uterus is normal
Endometrial cavity is T-shaped / irregular shaped
Can be caused by inutero exposure to diethylstilbestrol syndrome (DES). Diethylstilbestrol is a drug that was given during the 1940’s to early 1970’s to women for treatment of a threatened abortion
Predisposes female off-spring to having abnormal endometrial shapes and/or adhesions in the endometrium
what other system may have an anomaly associated w/ a mullerian duct anomaly?
what side?
urinary system anomaly e.g. renal agenesis, pelvic kidney
ipsilateral (same side)
–Some say 50% of patients with a renal anomaly will have reproductive anomaly so, check both
what type of anomaly:
Atresia is the congenital absence or closure of a normal body opening or tubular structure
This condition may be suspected when a female develops hydrocolpos
Note this diagram has uterine atresia too
Műllerian Duct & Urogenital Sinus Anomalies
Vaginal Atresia (no vagina)
*not usually found unless someone notices they aren’t having a period
aside from vaginal atresia, what other types of anomalies might be associated with Műllerian Duct & Urogenital Sinus Anomalies?
Vaginal Septum
Vaginal duplication
*These conditions may be suspected when a female uses tampons yet still has to wear a
what remnant of embryology is the following referring to?
A young girl begins her menstruation however; the menstrual flow cannot reach the outside through the hymen thus the vagina gradually becomes distended with blood (hematocolpos). The continued menses each month will cause pressure. The enlarging amount of blood can predispose her to infection. This situation may go on until the adolescent seeks her mothers help and they seek medical attention. In the early stages the pressure causes the hymen to bulge, the old blood will remain in the uterus (hematometrocolpos) and can exit through the tubes (hematosalpinx) and can rupture into the peritoneal cavity
imperforate (lacking the normal opening) hymen
–May have no symptoms prior to puberty and go unrecognized unless detected by careful physical exam
What normally occurs as a child ages is the hymen becomes web-like which will allow the menses to flow out of her body at puberty. With imperforated hymen the menses becomes trapped.
what clinical findings can an imperforated hymen cause? (2)
Hydrocolpos is a fluid filled vagina
hydrometrocolpos, Fluid filled vagina and uterus
(Metro is uterus)
hematometrocolpos (Blood filled vagina and uterus)
in image below Note the bulging hymen, Dilated vagina, and Dilated endometrium and dilated tube
(Hydro is fluid, Colpos is vagina)
_________ Can occur during the neonatal period. A newborn may present with a large cystic pelvic-abdominal mass because of the stimulation from her mothers hormones while in-utero.
in US it appears as an anechoic, pear-shaped mass with no normal vaginal echoes located adjacent and posterior to the bladder
hydrocolpos
what would hydrometrocolopos look like in US?
Anechoic fluid in the vagina and uterus
The cervix may be difficult to visualize
what remnant of embryology is represented here? how do you know?
Heterogeneous, homogeneous or hyperechoic fluid collection with clots or particles depending on the age of the blood
Blood changes its’ sonographic appearance depending on its’ age
This TA long midline image demonstrates the fluid/blood in the vagina
Note the posterior enhancement demonstrates it is fluid filled
Note the pressure is beginning to distended the endometrium
what might this indicate?
Case of Imperforate Hymen: Hematocolpos
This is a TA Longitudinal, low midline image in young patient with imperforate hymen. The image shows distended vagina filled with homogeneous solid appearing material that is compressing the bladder (b) anteriorly
The posterior enhancement proves this is fluid NOT solid
this is a case of _______________ due to imperforate hymen
hematometrocolpos
what is the most common uterine tumor?
leiyoma aka fibroid, myoma
_______ is a Smooth muscle tumor of the uterine wall and consists of a whorled, spherical configuration of myometrial tissue that can degenerate into a number of different histological subtypes
Leiomyoma (most common benign uterine tumor in a woman of reproductive years 20% to 30%)
what are some common clinical findings with leiyomyomas?
more common in african american women
Patient is usually asymptomatic but may have pain, congestive or pressure symptoms and abnormal bleeding
Uterine enlargement
Patient is usually over 30 years of age
the following lab data most closely represents
Estrogen dependent
Known to increase in size with pregnancy
No significant lab findings
Patients taking Tamoxifen may increase their risk of developing leiomyomas
leiomyoma
*lady gets pregnant, estrogen increases and leiomyoma’s appear. menopausal lady takes estrogen supplement, leiomyomas appear.
what are the 3 location leiomyomas are found? which is the most common
Subserosal – Projecting from the peritoneal surface
Can be pedunculated or stalk-like
Can appear as extrauterine masses
Intramural - Most common type, Confined to myometrium
Associated with infertility
Submucosal - Projecting into the uterine cavity
Associated with infertility & heavy bleeding
*note all of these are hypoechoic compared to the myometrium
the following are common US findings w/ ______
Uterine enlargement can occur
May be multiple, of variable sizes, in various uterine locations
May produce sound attenuation and/or shadowing
May calcify
Typically hypoechoic compared to uterus
May be heterogeneous in echotexture
May degenerate & have a central area of hemorrhage or necrosis
leiomyoma
this Calcified around the edges (echogenic around periphery is a variable US finding of _________.
leiomyoma.
as is the below however this one
Internal Cystic Degeneration (heterogeneous) distorting external countours of the uterus and the patient is pregnant
what variable is this leiomyoma represent?
Calcified contents causing shadowing
Images
____________ is a Malignancy thought to arise from a preexisting leiomyoma
Fast growing
Rare (Makes up less than 5% of uterine malignancies per Hagen-Ansert)
Can affect any age
Leiomyosarcoma (sarcomas grow faster than carcinomas look similar to degenerating leiomyoma)
what clinical findings are associated w/ leiomyosarcoma?
Similar to leiomyomas
Rapid enlargement of leiomyoma in post or peri-menopausal woman raises suspicion
Uterine bleeding
(similar to leiomyoma on US)
what type of uterine pathology
Sarcoma of the uterus most commonly seen in infants & children
(Malignancy we will cover in Pediatric Gyn lecture)
Very rare, polypoid mass has ‘grape-like’ clusters
Sarcoma Botryoides
what uterine pahtology is:
Benign, abnormal overgrowth of the endometrium
Caused by unopposed estrogen
Rare in women with normal menstrual cycles
Risk increases with oral contraceptives or estrogen replacement therapy after menopause
Associated with Tamoxifen (used to treat advanced breast cancer & acts like estrogen in most tissue except breast)
endometrial hyperplasia (overgrowth)
the following clinical findings indicate _______
Bleeding between normal menstrual periods
Heavy menstrual flow (saturating a tampon or pad once every hour)
Bleeding after menopause
A biopsy is used to confirm diagnosis
endometrial hyperplasia
what type of uterine pathology?
endometrial hyperplasia
Appears as thickening of the endometrium
Endometrial stripe measurement greater than
14 mm (double thickness) in pre-menopausal woman or woman on hormone replacement therapy
8 mm (double thickness) in postmenopausal woman not on hormone replacement therapy
TV coronal image of the uterus with a very prominent, echogenic endometrium measuring more than 23 mm. Biopsy confirmed the patient had endometrial hyperplasia
DDX for endometrial hyperplasia (most common)
Endometrial polyps
Endometrial carcinoma
the below
Benign, diffuse or focal endometrial thickening
that May cause abnormal bleeding, fertility issues or pregnancy loss represents _______
they are best seen w/ SIS.
endometrial polyps
a majority of endometrial carcinomas are _________
adenocarcinomas
______________ is
Cancer of the endometrial lining
Majority are adenocarcinomas
Malignancy associated with estrogen stimulation
Clinical Findings
Post-menopausal bleeding
Pain
May not have pain in early stages
More common in post-menopausal women
Usually between 50 & 60 years
endometrial carcinoma
What is the best differential diagnosis for what the white arrows are pointing to? Give 3 names
Fibroid
Leiomyoma
Myoma
What is the differential diagnosis?
uterus didelphys
What are the arrows pointing to? Be very specific
lippes loop iud
What is the best differential diagnosis for what the white arrow is pointing to?
Leiomyoma
Appears to be pedunculated – Don’t confuse with an adnexal mass
label the pathology
Label the following anomalies b-g (a is normal)
A is normal
B arcuate
C,D,E, F & G are all sub septate uteri with various lengths
Note f on conventional US (top 2 images) appears normal
(F & G are same pt
_________ is a benign condition that has a presence of endometrial tissue in abnormal locations outside the uterus
Occurs most commonly in ovarian wall, tubes, broad ligament, posterior cul-de-sac, retrovaginal septum
endometriosis
______ has the Presence of endometrial tissue in abnormal locations outside the uterus
Occurs most commonly in ovarian wall, tubes, broad ligament, posterior cul-de-sac, retrovaginal septum
Cyclic pain
endometriosis
what’s the medical term for a chocolate cyst? what is it?
endometrioma
Focal form of endometriosis
(old blood in cyst)
this clinical findings best represent
________
Cyclic pain
The endometrial tissue cyclically bleed and proliferates as stimulated by hormones
Dyspareunia
Dysmenorrhea
Hematuria
Affects females between puberty & menopause
Typical age is mid late 20’s & 30’s
No significant lab findings
endometriosis
*pregnancy can cure the chronic discomfort associated w/ endometriosis
what form of endometriosis is
Difficult to see on US because implants are so small
There may be a disorganization of the pelvic anatomy similar to PID or chronic ectopic pregnancy
diffuse form
what form of endometriosis
Endometrioma AKA ‘chocolate cyst’
Well-defined predominately cystic mass with enhancement
Thick walls and irregular borders
Typically they have low-level internal echoes
Differential diagnosis is hemorrhagic cyst
Image
localized form
what uterine pathology:
Benign condition when endometrial cells have penetrated deep into the myometrium
Typically affects the posterior uterine wall
Can be
Diffuse (more common)
Focal
Associated with endometriosis
adenomyosis
the following are clinical findings of ________
Similar to endometriosis symptoms except adenomyosis is not cyclic pain
Uterine size may be normal or enlarged
Typically occurs in premenopausal and perimenopausal, multiparous women over 30 years old
Painful, heavy menses
Hypermenorrhea
Metrorrhea
Menorrhagia
Can cause infertility
adenomyosis
what type of uterine pathology is this?
how can you tell?
Small myometrial cysts cause hypoechoic, heterogeneous myometrium
Diffusely enlarged
Difficult to diagnose on US, don’t confuse with fibroids
Note this lacks a hypoechoic border that is seen with fibroids
what iud is this?
Lippes loop
Serpentine shape
On Longitudinal US Image
5 Distinctly separate echogenic ‘dotted line’, with shadowing inside the endometrium
Scan plane (dotted line) needs to be perpendicular to the IUD to get the characteristic shadowing
which iud is this?
mirena
which iud is this?
Dalkon Shield
On both longitudinal & transverse it appears as 2 echogenic foci
Insertion of this was suspended some years ago because of a large number of associated infections
There are still a few women
