Acute female pelvic pain: Ultrasound evaluation

Ultrasound has become a valuable primary imaging tool in the assessment of acute pelvic pain in women, both for diagnosis and for assessment of complications. Although ultrasound is an established imaging tool for gynecologic diseases, it is also a useful modality for assessing nongynecologic disorders that cause acute pelvic pain, such as diverticulitis and urinary tract calculi. These are important differential diagnoses in women with acute pelvic pain, and sonologists are not always expert in their diagnosis. This article reviews the gamut of conditions that can cause acute pelvic pain in women. The usual gynecologic causes are included, such as ectopic pregnancy, but also considered are conditions such as diverticulitis, appendicitis, and incarcerated hernia, which are important differential considerations.     

Sonography of Gastrointestinal Tract Diseases

Sonographic evaluation of the gastrointestinal (GI) tract may be difficult because of overlying intraluminal bowel gas and gas‐related artifacts. However, in the absence of these factors and with the development of high‐resolution scanners and the technical experience of radiologists, sonography can become a powerful tool for GI tract assessment. This pictorial essay focuses on sonographic findings of GI tract lesions compared with endoscopic, computed tomographic, and magnetic resonance imaging findings. Neoplastic and non‐neoplastic diseases and postoperative complications are illustrated, and the distinctive sonographic characteristics of these entities are highlighted.     

Acute HIV-related gastrointestinal disorders and complications in the antiretroviral era: spectrum of cross-sectional imaging findings

Emergency physicians and radiologists are increasingly confronted with aging HIV-positive or acquired immunodeficiency syndrome (AIDS) patients with acute abdominal symptoms, who often require immediate medical or surgical treatment. A wide spectrum of infectious and neoplastic HIV-related gastrointestinal diseases may be encountered, along with atypical presentations of common disorders. Since symptoms and physical findings are commonly nonspecific or masked by concurrent illnesses, medications, and weak immune response, prompt cross-sectional diagnostic imaging studies are needed to triage patients and choose treatment. Multidetector CT currently represents the mainstay modality to promptly investigate intra-abdominal opportunistic disorders in HIV/AIDS patients, and MRI is increasingly used to assess abnormalities involving the rectum. The spectrum of cross-sectional imaging appearances of HIV-related acute gastrointestinal disorders and complications observed in the antiretroviral era is reviewed, including acute intestinal infections, causes of right lower quadrant pain, bleeding, bowel obstruction, and perforation. State-of-the-art technology, knowledge of pertinent clinical information, and familiarity with the spectrum of opportunistic diseases are necessary to improve diagnostic confidence in the detection and characterization of gastrointestinal abnormalities on urgent cross-sectional abdominal studies performed in HIV-infected patients.     

From esophagus to rectum: a comprehensive review of alimentary tract perforations at computed tomography

Gastrointestinal (GI) tract perforation is a life-threatening condition that can occur at any site along the alimentary tract. Early perforation detection and intervention significantly improves patient outcome. With a high sensitivity for pneumoperitoneum, computed tomography (CT) is widely accepted as the diagnostic modality of choice when a perforated hollow viscus is suspected. While confirming the presence of a perforation is critical, clinical management and surgical technique also depend on localizing the perforation site. CT is accurate in detecting the site of perforation, with segmental bowel wall thickening, focal bowel wall defect, or bubbles of extraluminal gas concentrated in close proximity to the bowel wall shown to be the most specific findings. In this article, we will present the causes for perforation at each site throughout the GI tract and review the patterns that can lead to prospective diagnosis and perforation site localization utilizing CT images of surgically proven cases.     

Pitfalls in detection of acute gastrointestinal bleeding with multi-detector row helical CT

Contrast-enhanced multi-detector row helical CT angiography is establishing itself as an accurate, rapid, and non-invasive diagnostic modality in patients with acute gastrointestinal bleeding. On arterial phase MDCT images ongoing hemorrhage can be revealed as an area of active extravasation of contrast material within the bowel lumen. This pictorial essay gives a short overview of current diagnostic modalities in assessing acute GI tract bleeding, typical MDCT findings, and depicts potential pitfalls in the detection of acute GI bleeding with MDCT.     

Amyloidosis of the alimentary canal: radiologic–pathologic correlation of CT findings

Background: The purpose of the study was to describe the computed tomographic (CT) findings of the alimentary canal and mesentery in amyloid infiltration of the gastrointestinal (GI) tract and to correlate the CT findings with histologic extent and distribution and with amyloid subtype. Methods: Abdominal CT scans performed between 1988 and 1997 on patients with pathologically proven amyloidosis of the alimentary canal were reviewed for abnormalities of the alimentary canal and mesentery. Histology was graded for extent of mucosal, submucosal, and muscularis propria involvement and for degree of interstitial and vascular distribution. CT findings were correlated with histologic extent, histologic distribution, and amyloid histochemical type. Results: Twenty-three patients were included. Four (17%) had bowel wall thickening, which was associated with a higher submucosal extent and interstitial distribution than in patients with normal bowel by CT. Four (17%) patients had bowel wall dilatation without thickening, which was not associated with statistically significantly different histology than in patients with normal bowel by CT. There was no statistically significant correlation between CT findings and histochemical subtype. Mesenteric soft tissue infiltration was seen in two patients, and mesenteric adenopathy was seen in one patient. Conclusions: Normal bowel is a common abdominal CT finding in amyloidosis of the alimentary canal. When findings are present, GI wall thickening and/or bowel wall dilatation without wall thickening may be seen. Bowel wall thickening on CT correlates with submucosal extent and interstitial distribution of disease. Soft tissue infiltration and adenopathy are also occasionally seen. Received: 15 January 1999/Accepted: 10 March 1999     

MRI of fetal GI tract abnormalities

We describe the magnetic resonance (MR) patterns of a variety of fetal gastrointestinal (GI) abnormalities. Thirty-two fetuses between 23 and 38 weeks gestation with abnormal appearance of the GI tract by ultrasound underwent MR imaging with T1- and T2-weighted sequences. The MR aspect of intestinal atresia (duodenal atresia, one case; small bowel atresia, nine cases) included dilatation of the bowel loops, accurate assessment of the normal bowel distal to the atresia (except in the patient with multiple atresia and apple-peel syndrome), and micro-rectum with decreased T1 signal (except in the patient with duodenal atresia). Megacystis-microcolon-intestinal hypoperistalsis syndrome (one case) was indicated by an abnormal signal of the entire bowel and an abnormal pattern for the urinary tract. Meconium pseudocysts (two cases) were easily differentiated from enteric cysts (two cases). High anorectal malformations with (two cases) or without (one case) urinary fistula and cloacal malformation (one case) are described and MR findings are discussed. The capability of MR imaging to demonstrate the normal bowel with intraperitoneal anomalies (e.g., congenital diaphragmatic hernia, and sacrococcygeal teratoma) is emphasized. MR imaging is informative in the diagnosis of GI tract abnormalities, especially the severe malformations, with much more accuracy than sonography.     

Multimodality imaging of small bowel neoplasms

Although the small intestine accounts for over 90% of the surface area of the alimentary tract, tumors of the small intestine represent less than 5% of all gastrointestinal tract neoplasms. Common small bowel tumors typically are well evaluated with cross-sectional imaging modalities such as CT and MR, but accurate identification and differentiation can be challenging. Differentiating normal bowel from abnormal tumor depends on imaging modality and the particular technique. While endoscopic evaluation is typically more sensitive for the detection of intraluminal tumors that can be reached, CT and MR, as well as select nuclear medicine studies, remain superior for evaluating extraluminal neoplasms. Understanding the imaging characteristics of typical benign and malignant small bowel tumors is critical, because of overlapping features and associated secondary complications.

     

Acute gastrointestinal bleeding: contrast-enhanced MDCT

With the introduction of multidetector row computed tomography (MDCT), CT is being considered a potential diagnostic method for patients with acute gastrointestinal (GI) bleeding. On arterial phase MDCT images, active GI bleeding is typically identified as a focal area of high attenuation within the bowel lumen, which represents a collection of contrast material that has been extravasated in association with arterial bleeding. Additional CT findings suggestive of acute GI bleeding are focal dilatation of fluid-filled bowel segment noted on contrast-enhanced CT and acute hematoma on unenhanced CT. In addition to detection of active bleeding, an advantage of contrast-enhanced MDCT is the ability to demonstrate morphologic changes in the GI tract, which could suggest specific conditions that cause acute GI bleeding such as intestinal tumors. Arterial phase contrast-enhanced MDCT is rapid, noninvasive, and accurate in detecting and localizing sites of bleeding in patients with acute GI bleeding. Contrast-enhanced MDCT may be a promising diagnostic option in patients with acute GI bleeding.     

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group

Premenopausal women who present with acute pelvic pain frequently pose a diagnostic dilemma, exhibiting nonspecific signs and symptoms, the most common being nausea, vomiting, and leukocytosis. Diagnostic considerations encompass multiple organ systems, including obstetric, gynecologic, urologic, gastrointestinal, and vascular etiologies. The selection of imaging modality is determined by the clinically suspected differential diagnosis. Thus, a careful evaluation of such a patient should be performed and diagnostic considerations narrowed before a modality is chosen. Transvaginal and transabdominal pelvic sonography is the modality of choice when an obstetric or gynecologic abnormality is suspected, and computed tomography is more useful when gastrointestinal or genitourinary pathology is more likely. Magnetic resonance imaging, when available in the acute setting, is favored over computed tomography for assessing pregnant patients for nongynecologic etiologies because of the lack of ionizing radiation. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every two years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.     

CT与胃肠道造影诊断小肠原发恶性肿瘤的比较研究

目的评价CT和常规胃肠道造影对小肠原发恶性肿瘤诊断的准确性。方法收集52例经手术和病理证实小肠原发恶性肿瘤的胃肠道造影、CT、血管造影及临床资料,回顾性分析其胃肠道造影和CT影像特征,并与手术和病理学结果进行对照。结果 52例小肠原发恶性肿瘤中腺癌19例,恶性间质瘤10例,恶性淋巴瘤23例。常规胃肠道造影主要表现为肠管狭窄、充盈缺损、管壁僵硬、黏膜破坏及环状皱襞消失、肠梗阻、肠套叠及溃疡形成等,41例得到了准确定位,肯定肿瘤诊断32例。CT检查20例,主要表现为局部肠壁增厚、小肠肿块、肠管狭窄、肠梗阻、肠套叠等,均得到了准确定位,肯定肿瘤诊断18例。肠系膜上动脉造影3例,均明确了出血的部位,但术前均误诊为血管畸形。结论 CT对小肠原发恶性肿瘤的诊断具有更高的准确性,并能提供有关肿瘤局部浸润、淋巴结远处转移以及并发症等影像学信息,常规胃肠道造影与CT检查相结合有助于制订出更为恰当的治疗计划。     

Acupuncture for gastrointestinal and hepatobiliary disorders

Acupuncture has been used for various gastrointestinal (GI) conditions. Voluminous data support the effect of acupuncture on the physiology of the GI tract, including acid secretion, motility, neurohormonal changes, and changes in sensory thresholds. Much of the neuroanatomic pathway of these effects has been identified in animal models. A large body of clinical evidence supports the effectiveness of acupuncture for suppressing nausea associated with chemotherapy, postoperative state, and pregnancy. Prospective randomized controlled trials have also shown the efficacy of acupuncture for analgesia for endoscopic procedures, including colonoscopy and upper endoscopy. Acupuncture has also been used for a variety of other conditions including postoperative ileus, achalasia, peptic ulcer disease, functional bowel diseases (including irritable bowel syndrome and nonulcer dyspepsia), diarrhea, constipation, inflammatory bowel disease, expulsion of gallstones and biliary ascariasis, and pain associated with pancreatitis. Although there are few prospective randomized clinical studies, the well-documented physiological basis of acupuncture effects on the GI tract, and the extensive history of successful clinical use of acupuncture, makes this a promising modality that warrants further investigation.     

Adrenal and pseudoadrenal masses: CT and US findings

Computed tomography (CT) is currently the imaging modality of choice for assessing the morphology of the adrenal glands in adult patients. Much useful information can be gained using CT in disease processes which primarily involve one or both of the adrenal glands, such as adenomas, as well as in entities which secondarily affect the adrenals, such as pituitary or metastatic disease. The size and configuration of the glands can be readily determined, and masses may be detected. We discuss CT of normal and abnormal adrenal glands with sonographic (US) and pathological correlation, when available. Entities which may mimic adrenal abnormalities are emphasized. Relative advantages of US over CT in the pediatric patient are discussed.     

Pelvic endometriosis: US and MRI features

Endometriosis represents a common and important clinical problem of women of childbearing age. It is a disabling disorder manifesting with pain and infertility. The exact pathogenesis of the disease remains unclear, despite the different theories that have been formulated. The literature on endometriosis is extensive, but often in regard to classic endometrioma. It is surprising that, to the best of our knowledge, the many radiologic features of extraovarian endometriosis have not been well documented thus far. Although ultrasound (US) remains the imaging modality of choice in the radiologic evaluation of female patients with pelvic pain, the role of magnetic resonance imaging (MRI) in the evaluation of abdominal pain is expanding. In the young patient, MRI may be performed if a gynecologic disorder is not suspected at first, especially if US findings are equivocal or the abnormality extends beyond the field of view of the sonographic probe. Moreover, MRI is useful whenever further characterization of pelvic disorder is required. In fact, many causes of pelvic disorders and of endometriosis in particular demonstrate characteristic MRI findings. For these reasons, in this work we describe the protean US and MRI appearances of endometrial foci as encountered in daily experience.     

Magnetic resonance imaging of nongynecologic pelvic masses in children

Pelvic neoplasms can arise from the genitourinary tract, gonads, soft tissues, or bone. The role of imaging is to confirm the presence of tumor, determine the site of origin, delineate the extent for staging and treatment planning, and serve as a baseline for monitoring response to therapy. MR imaging is well suited for the characterization and staging of pediatric pelvic tumors. This article reviews the imaging findings and staging evaluation of the common nongynecologic neoplasms in children. Prostatic, bladder, gonadal, and sacrococcygeal tumors are discussed. Gynecologic tumors are discussed elsewhere in this issue.     

CT and MR enterography in evaluating small bowel diseases: when to use which modality?

MR and CT techniques optimized for small bowel imaging are playing an increasing role in the evaluation of small bowel disorders. Several studies have shown the advantages of these techniques over traditional barium fluoroscopic examinations due to improvements in spatial and temporal resolution combined with improved bowel distending agents. The preference of MR vs. CT has been geographical and based on expertise and public policy. With the increasing awareness of radiation exposure, there has been a more global interest in implementing techniques that either reduce or eliminate radiation exposure. This is especially important in patients with chronic diseases such as inflammatory bowel disease who may require multiple studies over a lifetime or in studies that require sequential imaging time points such as in assessment of gastrointestinal motility. MRI has many properties that make it well suited to imaging of the small bowel: the lack of ionizing radiation, the improved tissue contrast that can be obtained by using a variety of pulse sequences, and the ability to perform real time functional imaging. Moreover, MR modalities allow visualization of the entire bowel, without overlapping bowel loops, as well as the detection of both intra- and extraluminal abnormalities.The intra- and extraluminal MR findings, combined with contrast enhancement and functional information, help to make an accurate diagnosis and consequently characterize small bowel diseases.     

胆道疾病的影像检查(附486例报告)

目的 评价各种影像检查方法在胆道疾病诊断中的价值。方法 回顾性复习486例经手术病理证实的胆道疾病影像资料,分析各检查方法的优势和局限性。结果 26例胆囊内阴性结石在传统造影中显示清楚。胆道直接造影能清楚显示胆道解剖形态及病因。B超和CT对胆道结石诊断阳性准确率为91.3%和90.3%,13例泥沙样胆石CT漏诊。超声诊断慢性胆囊炎和胆囊息肉符合率达100％和93.3%。MRCP的“胆管树”有助于肝门胆管癌的确诊。结论 传统造影法能较好显示胆囊阴性结石,胆道直接造影为定性诊断提供重要依据。B超和CT显示胆道结石优于其他方法。超声是慢性胆囊炎和息肉样病变最好检查方法。MRCP是诊断重度胆道梗阻的理想影像手段。     

Endoscopic ultrasound of the upper gastrointestinal tract

Endoscopic ultrasound (EUS) is an evolving technique used by gastroenterologists to examine lesions that are located either within or adjacent to the walls of the upper gastrointestinal (GI) tract; this topic is relatively unknown to most radiologists. Proper use of this modality is benefited by a cooperative effort between gastroenterologists and radiologists specializing in ultrasound and cross-sectional imaging. This article informs radiologists of the applications of this procedure. Most patients are examined with EUS after a biopsy of a mucosal tumor has been performed. A smaller number are performed to evaluate submucosal masses or when pancreatic disease is suspected but not diagnosed. The examinations can be performed either with dedicated flexible echoendoscopes or with catheter-based probes passed through a conventional endoscope. The exact location of abnormalities associated with the upper GI tract can be observed. Known anatomic landmarks are sought. Abnormalities of structures outside the upper GI tract will occasionally be found during these examinations. The specific layers of the walls of the gut are examined, and the T and N-classification of upper GI tumors can be determined accurately. The performance of an EUS examination requires advanced skills, and in many medical centers, it is the imaging modality of choice to stage cancers, to evaluate submucosal masses, and to investigate both malignant and benign pancreaticobiliary disease. Endoscopic ultrasound is sensitive but not specific, and biopsy is necessary to establish a diagnosis. Therapeutic applications of EUS are evolving. Specialized applications with catheter-based probes are also being developed.     

Applications of magnetic resonance imaging to gynecology

The advent of MRI has improved the ability of the diagnostic radiologist to provide useful clinical information to the practicing gynecologist. Although US remains the screening procedure of choice for evaluation of the uterus and adnexa because of its relative safety and low cost, MRI is now considered the next imaging step. In a woman with pelvic pain, MRI can accurately identify adenomyosis, enumerate and localize uterine fibroids, and provide more accurate identification of endometriosis and cystic teratomas of the ovary than US. Although MRI should not be used as a screening procedure for diagnosing endometrial or cervical carcinoma, it can aid in patient management by determining the extent of myometrial or cervical invasion by endometrial carcinoma and can be used to calculate tumor volume in patients with cervical carcinoma. Early studies suggest that MRI may be helpful in distinguishing between long-term radiation fibrosis and tumor recurrence in such patients. MRI findings may be highly indicative of the presence of ovarian malignancy, but the procedure adds little to CT or US findings. Nevertheless, MRI is superior in the localization of pelvic masses and is often indicated in clarifying the origin of a mass as uterine or ovarian.     

Computed tomographic and magnetic resonance features of gynecologic abnormalities in women presenting with acute or chronic abdominal pain

Advances in technology and improved availability have led to increased use of computed tomography (CT) and magnetic resonance imaging (MRI) to evaluate women presenting to the emergency department or to their primary care provider with abdominal and/or pelvic pain. Computed tomographic examinations are often performed to evaluate the presence of appendicitis or renal stone disease. However, gynecologic abnormalities are frequently identified on these examinations. Although ultrasound remains the primary modality by which complaints specific to the pelvis are evaluated, in many instances, CT and MRI imaging occurs before sonographic evaluation.Historically, because of cost, radiation exposure, and relative ease of use, ultrasound examinations have preceded all other imaging modalities when evaluating pelvic disorders. However, as CT and MRI technology have improved, their use in diagnosing causes of pelvic pain has become equal to that of ultrasound. In some cases, primarily because of historic comfort with sonographic evaluation, gynecologic abnormalities originally diagnosed on CT or MRI may be immediately and unnecessarily reevaluated by ultrasound.For a woman in her reproductive years, the most common adnexal masses are physiological cysts, endometriomas, and cystic teratomas. Although lesions are often asymptomatic and incidentally detected, they can present with pain, and they increase the risk of ovarian torsion. Common causes of chronic pelvic pain in this population include leiomyomata and adenomyosis. In postmenopausal women, ovarian carcinoma, which often does not present clinically until a late stage, has to be included in the differential diagnosis of adnexal masses.If a gynecologic pathology is discovered on CT or MRI, an immediate follow-up ultrasound need not be pursued if the lesion can be characterized as benign, needing immediate surgical intervention, or a variant of normal anatomy. If, on the other hand, findings demonstrate a mass that either is uncharacteristic of a benign lesion, has an indeterminate risk for malignancy, or demonstrates suspicious characteristics for malignancy (such as enhancing mural nodules), further evaluation by serial ultrasound, biochemical marker, and/or CT or MRI is warranted.The purpose of this review is to present a series of commonly encountered gynecologic abnormalities with either CT or MR to make radiologists more familiar with gynecologic pathology on CT and MRI.