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Pelvic inflammatory disease and its sonographic diagnosis

Poster No.: C-1258


Congress: ECR 2010
Type: Educational Exhibit
Topic: Genitourinary
Authors: 1 2 1 1 2
S. Speca , G. Soglia , L. Bonomo ; Rome/IT, rome/IT
Keywords: pelvic inflammatory disease (PID), sonographic diagnosis of PID,
differential diagnosis of PID
DOI: 10.1594/ecr2010/C-1258

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Learning objectives

The learning objectives of this educational exhibit are

- To describe sonographic characteristics of Pelvic Inflammatory Disease (PID);

- to distinguish between acute and chronic diseases;

- to demonstrate the extension of the disease.

Background

Pelvic inflammatory disease is a pelvic organs infection (female genital organs infection,
which involves not only the reproductive ways, but also other endopelvic structures and
the peritoneal serous), caused by micro-organisms'rise from vagina and cervix to the
superior genital ways, including cervicitis, vaginitis, endometritis, salpingitis and ovaritis
(Fig.1) on page 3.

WHEN BACTERIA (exogenous and endogenous agents - Fig. 2)on page 4


REACH THE INTERNAL GENITAL DELICATE EPITHELIUM, AN INFLAMMATORY
REACTION IS ROUSED AS A REPLY TO THE INFECTION, AND THIS LEADS TO THE
DESTRUCTION OF EPITHELIUM ITSELF .

Epidemiology on page 4 and pathogenesis (risk and protective factors)on page


5 are included in Figures 3 and 4.

PID can arise acutely with fever, pelvic pain, spotting, irregular menses, urinary or enteric
troubles, even if in some cases it can have a subdol course.

It's needed an early diagnosis to avoid severe consequences, as surgery on genital tract,
sterility or an increased risk of ectopic pregnancies.

THE COMMON CLINICAL CRITERIA USED FOR THE DIAGNOSIS OF TUBAL


INFECTIONS ARE NOT SPECIFIC

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Sonography is the first-step imaging technique to direct fastly the treatment. on page
6

Gold standard diagnostic procedure is surely laparoscopy.

Images for this section:

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Fig. 1: Pathogenesis of pelvis phlogosis

Fig. 2: Exogenous and endogenous vaginal agents

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Fig. 3: PID epidemiology

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Fig. 4: PID pathogenesis

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Fig. 5: PID diagnosis

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Imaging findings OR Procedure details

Tubes are hardly identifiable with sonoghaphy.

Fig.: Transvaginal sonography , uterine transversal scan connected with the left tubal
angle. Tube interstitial portion appears as a thin hyperechoic stripe surrounded by
miometrium (arrow)
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

Sonographic pattern of this complex disease could be heterogeneous with reference to


its stage.

1. Edematous salpinx (edematous and hyperemic tubes)

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Fig.: Sonographic diagnosis edematous salpinx
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

Edema and endosalpingeal folds' thickening allow tubes visualization with ultrasound.

As the lumen occludes distally, the tube distends and fills with fluid.The result is a
pyosalpinx. on page 20

2. Pyosalpinx

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Fig.: Sonographic diagnosis of pyosalpinx
References: S. Speca; radiology, university of sacred heart, Rome, ITALY
The acute inflammatory process can resolve spontaneously or thanks to medical
therapies.

It sometimes can proceed with the formation of a tubo-ovarian complex, where tube and
ovary are identify distinctly, but not dissociable exerting pressure with transducer. The
evolution is in the tubo-ovarian abscess, where the morfo-structural distinction of tubes
and ovaries is completely lost: these structures are no more identifiable separately. on
page 21

3. Tubo-ovarian complex

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Fig.: Sonographic diagnosis of tubo-ovarian complex
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

4. Tubo-ovarian abscess

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Fig.: Sonographic diagnosis of tubo-ovarian abscess
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

Cases report

1. Acute salpingitis, reduction of resistivity and pulsatility indices.

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Fig.: Acute salpingitis
References: S. Speca; radiology, university of sacred heart, Rome, ITALY
2. Tubo-ovarian ascess, with an extremely inhomogeneous echostructure that can make
the diagnosis very difficult. In this case the identification of the tubal artery, thanks to its
PROTODIASTOLIC NOTCH, led to the correcrt diagnosis.

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Fig.: Tubo-ovarian abscess: a difficult diagnosis
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

3. Chronic salpingititis, the 'beads-on-a-string' sign.

Tube wall is thin, the lumen is dilated and, on the wall, thin hyperechoic projections
protrude into the lumen. These are the degenerated and

flattened endosalpingeal fold remnants.

In the same patients we can see a haemorragic corpus luteum of the right ovary.

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Fig.: Sonographic diagnosis of chronic salpingitis
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

Differential diagnosis

a. EXTRAUTERINE PREGNANCY on page 22

Extra-uterine pregnancies in more than 90% of cases are tubal pregnancies. on page
23

- The identification of the gestational sac in the tube can be diffucult with sonography

- Serial sonographic examination and b-hCG levels can simplify the diagnosis (tipically,
during a tubal evolutive pregnancy hormonal levels are stable, while in case of
miscarriage they quickly decrease and during an intra-uterine pregnancy they quickly
increase)

- Not very often a diagnostic laparoscopy is needed

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Tubal pregnancy: Uterus wiyhout pregnancy sac and fluid in the pouch of Douglas

Fig.: Tubal pregnancy: sonographic findings 1


References: S. Speca; radiology, university of sacred heart, Rome, ITALY

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Fig.: Tubal pregnancy: sonographic findings 2
References: S. Speca; radiology, university of sacred heart, Rome, ITALY
Tubal pregnancy: high vascularization of the pregnancy sac, suggestive for a trophoblast
in active proliferation, and consequently for an evolutive echtopic pregnancy.

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Fig.: Tubal pregnancy: sonographic diagnosis 3
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

b. APPENDICITES

Ecographic diagnosis of acute Appendicitis

- STRETCHED APPENDIX DISTESA, UNCOMPRESSIBLE

- TRANSVERSE DIAMETER >6 MM

- THICKENED WALL >3 MM

- ROUNDED HYPER-VASCULARIZATION

Sensibility:70-94%

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Specificity: 90-100%

Fig.: Retrocecal appendicitis


References: S. Speca; radiology, university of sacred heart, Rome, ITALY
c. POST-APPENDICECTOMY ABSCESSES

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Fig.: Post-appendicectomy abscess
References: S. Speca; radiology, university of sacred heart, Rome, ITALY

Images for this section:

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Fig. 1: The way from salpingitis to pyosalpinx

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Fig. 2: The way from tubo-ovarian complex to tubo-ovarian abscess

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Fig. 3: Extrauterine pregnancies

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Fig. 4: Tubal pregnancy

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Conclusion

We want to highlight the important role of sonographic semeiotics, which allows to make
a correct diagnosis.

Transabdominal ultrasound, integrated if possible by an endovaginal exam and a Doppler


evaluation, can identify salpingitis (idro or pyosalpinx), tubo-ovarian complex or abscess,
and their extension to abdominal cavity (pelvis peritonitis).

Ultrasound allows a correct differential diagnosis

(luteal cyst, endometriosis, appendicitis or extra-uterine pregnancy).

Personal Information

Prof. Stefania Speca

Department of Radiological Sciences, Catholic University of the Sacred Heart, Rome,


Italy

Dr. G. Soglia

Department of Radiological Sciences, Catholic University of the Sacred Heart, Rome,


Italy

Prof. L. Bonomo

Department of Radiological Sciences, Catholic University of the Sacred Heart, Rome,


Italy

References

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- Transvaginal sonographic markers of tubal

inflammatory disease

I. E. Timor-Tritsch, J. P. Lerner, A. Monteagudo, K. E. Murphy and D.S. Heller

Ultrasound Obstet Gynecol 1998;12:56-66

- MRI IMAGING IN PELVIC INFLAMMATORY DISEASE: comparison with


laparoscopy and US

Timo A. Tukeva, MD.

Radiology, 1999, 210: 209-216.

- Ultrasound of pelvic inflammatory disease

Mindy M. Horrow, MD.

Ultrasound Quarterly, 2004; 20: 171-179

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