Diagnostic ultrasound ( PDFDrive )

CHAPTER 54 Pediatric Pelvic Sonography 1877
C
C
B
U
A RT OVARY SAG MEDIAL B C
Bladder
D
SUPINE
RT SAG ADNEXA
E
FIG. 54.11 Ovarian Torsion. (A) Sagittal sonogram in 9-year-old girl with right lower quadrant pain demonstrates a greatly enlarged avascular
right ovary that contains multiple, variably sized cysts. The ovary was easily untwisted at surgery and immediately regained normal color. (B) Ovarian
torsion complicating an ovarian cyst in a 16-year-old girl with pelvic pain. Transverse view of the pelvis shows the large anterior ovarian cyst (C)
compressing the bladder (B) (surgical proof of torsion). No ovarian parenchymal tissue was seen sonographically. U, Uterus. (C) Infarcted, encysted,
ovarian torsion in a 6-day-old girl with an abdominal mass. Sonogram of the right lower abdomen and pelvis demonstrates an oval, complex structure
within a larger cystic mass (C). (D) Sagittal view shows infarcted, encysted, torsed right ovary in newborn with cystic mass noted on prenatal
sonogram. A luid-debris level is noted within the cyst (arrows). (E) Transverse left decubitus scan shows encysted right ovary (arrows) embedded
in the wall of the cyst.
Hemorrhagic ovarian cysts occur in adolescents and have
a variety of sonographic patterns caused by internal blood clot
formation and lysis (Fig. 54.12). he most common appearance
is a heterogeneous mass that is predominantly anechoic and
contains hypoechoic material. Less oten, hemorrhagic ovarian
cysts are homogeneous, either hypoechoic or hyperechoic. Almost
all hemorrhagic cysts (92%) have increased sound through
transmission, indicating the cystic nature of the lesion. Additional
sonographic features include a thick wall (e.g., 4 mm), septations,
and luid in the cul-de-sac. Although the sonographic indings
are nonspeciic, the changing appearance of hemorrhagic ovarian
cysts over time, as a result of clot lysis, can help establish the
diagnosis. 33 In some cases the diagnosis can be confused with
appendiceal abscess, dermoid cyst, or teratoma. Rarely, pelvic
varices can masquerade as a multiseptated cystic mass (Fig.
54.13).
Polycystic Ovarian Disease
(Stein-Leventhal)
he primary clinical manifestations of polycystic ovarian disease
(polycystic ovary syndrome [PCOS], Stein-Leventhal syndrome)
are hirsutism and irregular menstrual bleeding caused by excess
ovarian androgens and chronic anovulation. 34 hese features
emerge late in puberty or shortly thereater. In patients with
obesity or insulin resistance, the severity of the presentation is
ampliied. he evolution of this condition during early adolescence
is not well understood, but it appears that abnormal activation
of the hypothalamic-pituitary-ovarian-adrenal axis occurs,
accompanied by speciic morphologic changes in the ovaries. 34
he changes in the ovaries have been termed “polycystic ovarian
morphology.” It was deined in adults by the Rotterdam criteria
as (a) one or both ovaries demonstrate 12 or more follicles
measuring 2 to 9 mm in diameter, or (b) the ovarian volume
exceeds 10 cm 35 (Fig. 54.14, Video 54.3). However, there is
controversy as to whether the same criteria can be applied to
adolescents. 36-39 hese criteria are based on TVS in adults. In the
adolescents, sonography is predominately performed transabdominally.
he transabdominal approach has decreased resolution
compared with TVS, which can limit evaluation of follicle number,
especially in obese patients. 36,39 However, sonography is still
valuable and frequently is used in the evaluation of an adolescent
girl suspected of having PCOS. 39,40 Long-term follow-up is
important in these patients because of the increased incidence