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 Adv a ntages • 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)
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