nongynecological causes of acute and chronic pelvic pain · • it is useful to classify pelvic...
TRANSCRIPT
Nongynecological causes of acute
and chronic pelvic pain
Amela Sofić
UKC Sarajevo
Bosnia and Herzegovina
• One of the most challenging problems in a clinical routine is the pelvic pain
• It is useful to classify pelvic pain as acute or chronic, because differ in their differential diagnoses
• The pelvic pain can be of gynecological and nongynecological origin
• The most common cause of nongynecological pain:
-appendicitis
-diverticulitis
-urinary calculus
-IBD
-inguinal hernia
Appendicitis -Conventional radiography
• Plain radiographs are normal in many patients with acute appendicitis
• An appendicolith is the most specific sign on plain radiographic films (in 10%)
Barium enema
• For evaluation of chronic appendicitis
• Its use is not necessary in the case of a clear presentation of acute appendicitis
Advantage
• Readily available
Disadvantages
• High incidence of nondiagnostic examinations
• Radiation exposure
• Insufficient sensitivity
• Invasiveness
Appendicitis -Ultrasound
Advantages
• Lack of radiation exposure, Non-invasiveness, Short acquisition time
• Graded-compression in a step-wise approach and aims to optimize visualization of the appendix
• Color Doppler US in detecting increased vascularity of the apendix
• High accuracy 90%; sensitivity 78%; specificity 83%
Disadvantages
• Intestinal peristalsis
• Pulsation of the iliac artery (when it is near apendix)
• Difficulties keeping the probe in the same location for a long time
• The US depends on the operator
• Sensitivity of US is lower than of CT/MRI
• Complementary MRI or CT may be performed if diagnosis remains unclear
Appendicitis-Contrast-enhanced CT
• CT findings in chronic appendicitis are the same as those in acute appendicitis
Advantages
• To evaluate adult patients
• Time-efficient
• Cost-effective
• Good characterization of periapendicular inflammatory changes, apsces and perforation
• High diagnostic accuracy of 95-98%; sensitivity 91%; specificity 90%
Disadvantages
• Radiation exposure
• The potential for anaphylactoid reaction if intravenous (IV) contrast is used
• Lengthy preparation time if oral contrast is used
• Patient discomfort if rectal contrast is used
Appendicitis-MRI
Advantages
• Better visualization of abnormal appendices and adjacent inflammatory processes
• Demonstrate the extent of inflammatory infiltration
• Visualization of the appendix in an atypical location
• Delineation of pathology
• Operator independence
• Ease of examination of obese patients
Disadvantages
• Use of IV contrast
• Claustrophobic patients
• The inability to observe an appendicolith in the lumen
• The inability to differentiate between gas and an appendicolith in the perforation site
Left colonic divertikulitis- Conventional radiography
Plain radiographs
• Free intraperitoneal air (perforation)• Signs of bowel ileus or obstruction
Barium enema
• It is primary method for patients with chronic diverticulitis
• Barium enema can superbly depict :
-diverticula
-colonic mucosa
-colonic lumen
-colonic spasm
muscle hypertrophy
Left colonic divertikulitis -Ultrasonography
• The ultrasound finding is rather unclear and depends on the stage of the disease
• US is not as widely used as a first imaging test
• US is occasionally useful in diagnosing of acute diverticulitis
• Sensitivity of 77 to 98% and a specificity of 80 to 99%
Advantages
• Can be used if CT is not available
• Inexpensive, noninvasive,readily available
Disadvantage
• May not be helpful in excluding diverticulosis or diverticulitis because of interference due to bowel gas
Left colonic divertikulitis-CT
Advantages
• CT is the technique of choice for the detection of acute diverticulitis
• CT has replaced barium enema in evaluation of diverticulitis
• CT is superior to US in the detection of free air and deeply located or small fluid collection
• Can help in evaluating :-inflammatory disease
-complications such as bowel obstruction, abscess
• Can exclud other a pelvic disease
• CT help to make modified Hinchey stage
• The grade of severity of acute diverticulitis
• CT sensitivity for diverticulitis is 79 to 99%
Disandvantages
• CT may fail to demonstrate early, mild cases of diverticulitis
• Potential difficulty in differentiating diverticulitis from colon carcinoma
• Limited availability in certain regions of the world
Left colonic divertikulitis -MRI
• MRI findings is similar to CT:
-bowel wall thickening
-pericolic stranding
-presence of diverticula
- complications
Advantages
• Radiation-free imaging
• MRI is also comparable with CT to identify alternative diagnoses
• Diagnose acute diverticulitis, with sensitivity of 86 to 94% and specificity of 88 to 92%
Lower ureteric, Vesico-Ureteric Junction stones-Plain radiograph
Advantages
• For low-dose initial investigation, plain film with ultrasound is used
• For follow up, plain film is useful when a stone is visible
• Calcium stones 1-2 mm can be seen
• Cystine stones 3-4 mm may be depicted
Disadvantages
• Smaller calculi and/or radiolucent stones may go undetected
• 5% of stones are not visible on plain film radiographs
• Uric acid stones are usually not seen
• Obstruction/hydronephrosis cannot be adequately assessed
Lower ureteric, Vesico-Ureteric Junction stones-Ultrasound
Advantages
• Stones are visible in the distal ureter at or near
the UVJ, especially if dilatation is present
• Good for characterizing lucent filling defects
•Features include:
-echogenic foci
-acoustic shadowing
- twinkle artefact on colour Doppler
- colour comet-tail artefact
•When stones are seen, with a specificity as high
as 90%
Disadvantages
• Some patients with acute obstruction have little
or no dilatation
• Limited sensitivity for smaller stones than 2 mm
• US does not depict the ureters well
Lower ureteric, Vesico-Ureteric Junction stones- Intravenous
urography-IVU
Advantages
• Provides physiological information related to the degree of obstruction
• The radiation dose is generally less than CT, but it is the same size
• It shows anatomical abnormalities that can predispose patients to stone formation
• Possibility of delayed recording and use of gravity in a tilted or upright position
• Distinction of external calcifications, organizational calculus
• Detection rate as high as 70–90%
Disadvantages
• Can only visualise radiopaque stones (80–90% of stones)
• Less sensitive to CT, especially for small or non-obstructive stones
• Intravenous contrast is required and can hide stones
• Lucent stones do not differ from the transitional cell carcinoma or blood clot
Lower ureteric, Vesico-Ureteric Junction stones -CT
Advantages
• CT is the modality of choice in the evaluation of acut pelvic urolithiasis
• CT is faster and more effective in detection of missed stones on IVU
• Nonenhanced CT is usually sufficient with the aid of US
• Stones with attenuation values < 200 HU are visible
• Sensitivity of 94-97% and a specificity of 96-100%
• Low-dose CT protocol can be used as the initial imaging technique
Disadvantages
• Stones at the UVJ may be difficult to distinguish from stones in the
bladder
(repeat scan through the UVJ in the prone position)
• Distinguishing a ureteric calculus from a phlebolith can be challenging
• Two signs are helpful:
comet-tail sign: favours a phlebolith
soft-tissue rim sign: favours a ureteric calculus
• CT urography (CTU or CT-IVU) gives both anatomical and functional
information
• With intravenous contrast in a single acquisition as opposed to the
multiple and more dynamic traditional IVU
• Visualization of other structures in the abdomen is also better with
CTU than with traditional IVU
Lower ureteric, Vesico-Ureteric Junction stones-MRI
Advantages
• MR urography -MRU in case of chronic urolithiasis
• When CT nor sonography can not explain the complicated state
• Useful in case of allergy to Iodine contrast material or radiation is contraindicated (during pregnancy)
• The T2w-MRU sequence performed with multiple coronal orientations and diuretic administration is sufficient to identify entirely the non-dilated ureter
• HASTE MR urography:
- allows rapid acquisition of images
- has similar accuracy to spiral CT
• MRU showes ureteric calculi 72% of calculi seen by CT
• MRU sensitivity is 93.8%
Disadvantages
• Relative unspecificity of filing defects based in detecting of stones
• Stones are not directly visible on MRI because they produce no signal
• Gadolinium-based contrast is linked with nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD)
Inguinal hernia- Computed tomography
• Using CT scans, the sensitivity in 83%, specificity 67-83%
Advantages
• Computed tomography (CT) remains the best available imaging tool for evaluation of acute inguinal hernias
• Visualisation of hernia sac and neck, and signs of edema and inflammation within the hernia sac and bowel wall
• Axial images examined first, then coronal or sagittal reformatted images are used for problem solving
• Many hernias spontaneously reduce if the patient lies relaxed in the supine position during the scan
• Valsalva maneuver during a fast helical sequence may increase sensitivity
• Useful if another disease process is present that may be mimicking a hernia
Disadvantage
• Diagnosis may depend on finding a fascial defect
Inguinal hernia -Ultrasonography
Advantages
• Is useful in non-urgent, chronic cases
• Real-time examination allows to perform Valsalva or other maneuvers that elicit hernia symptom
• Visualization of peristalsis in herniated bowel, which may assist in diagnosis
Disadvantages
• Fascial defects are difficult to identify with ultrasound
• An ultrasound finding may be unspecific in the case of herniation of fat tissue or omentum
Inguinal hernia - MRI
• Generally is not a first-line imaging technique
• MRI allows for hernia evaluation in multiple imaging planes
• MRI may be useful in cases difficult to characterize by CT such as Morgagni or traumatic hernias
• In the future, increased availability of MRI
IBD-Conventional radiography
Plain radiographs
• It is useful in case of obstruction or extraintestinal manifestations
Barium enema
• Useful in the detection of ulcerations cobblestoneappearance
• Usuful in evaluation of:
- tubular narrowed
- spasm
- sinus tracts and fistula
- chronic changes if they are obstructed
• Barium enema has a 95% accuracy rate in distinguishing Crohn disease from ulcerative colitis
IBD-Ultrasound
Advantages
• US is useful for Crohn's disease in the ileocaecal region with sensitivity up to 95%
• Can differentiates the acute ulcerative phase and chronically reparative phase
• Useful in the extensive extraintestinal manifestations of IBD
• Sensitivity of 75% and specificity of 95% in the detection of Crohn's disease
• Doppler shows an increase in vascularity in inflamed bowel segments
• US Doppler has sensitivity 91.4% andspecificity 96.1%,
• Endoscopic ultrasound of IBD in the pelvis refers to the evaluation of the rectum
IBD-CT
Advantages
• Like MRI, CT can depict:
- Segmental thickening, hickened folds due to oedema
- -extraluminal lesions, mesenteric and abdominal manifestations
- complications such as sinus tracts and fistulas
- flegmone and abdominal abscesses
• CT enteroclysis in evaluation IBD of small bowel
• Sensitivity of CT enteroclysis is 87% and specificity is100%
• CT colonography is reliable for colon analysis in distinguishing acute and chronic IBD
Disadvantages
• Differentiation between peristalsis and skip lesions may be difficult
• Limitation of artefacts are produced by collapsed small bowel loops
• CT enteroclysis not detect recurrence of disease
IBD-Routine MRI
Advantages
• Evaluation:
- extraintestinal manifestations of IBD
-perianal fistulae
-superficial ulceration
-loss of haustration
• For differentiate active inflammation from fibrosis
• Superior to CT scan and fistulography in assessing perineal complications
• Identifying the levator ani wich is a landmark for distinguishing supralevator abscesses
• MRI is superior to CT in the differentiation of fistulous tracts
IBD-MR colonography,MR enteroclysis
• Bright bowel wall due to increased signal of water on T2 sequences suggests disease activity
• Layered pattern of enhancement on T1 with gadolinium is highly specific for active disease
MR colonography
• MR colonography is an alternative to colonoscopy
• MR enteroclysis is reliable in evaluation of Crohn's disease of the small intestine
Advantages of MR enteroclysis
• It is superior to MR enterography for detecting Crohn's disease abnormalities
• It is the only method that excludes small bowel inflammatory and noninflammatory disease
• Can be a first line modality
Disadvantages of MR enteroclysis
• Inability to compress bowel in real time
• Not evaluate superficial abnormalities or fistulas
To take home
• The role of diagnostic imaging in evaluation of Nongynecological causes of acute and chronicpelvic pain is:
confirm the diagnosis
evaluate the severity and extent of disease
exclude alternative diagnoses
allow for treatment planning
• The decision to obtain diagnostic modality depends on:
institutional preference
available user expertise
important influencing factors:
patient age
patient sex
patient body habitus
• US and CT are the initial imaging test of choice in many cases
• But US is favor for patients due to the absence of ionizing radiation
• Conventional radiography has limited diagnostic value in the assessment of most patients with pelvic pain
• MRI is another emerging technique for the evaluation of pelvic pain that avoids ionizing radiation
• The choice of imaging technique depends on the clinical scenario
To take home