Diagnostic ultrasound ( PDFDrive )

CHAPTER 16 The Adnexa 587
A
B
FIG. 16.23 Hydrosalpinx. TVS images show tubular luid-illed structures with sonographic characteristics of the fallopian tube. (A) Incomplete
septation related to the folding of the tube (arrows). (B) A waist sign also associated with tubal folds (arrows) and endosalpingeal folds forming
surface nodularities. See also Videos 16.9 and 16.10.
abnormalities of the fallopian tube are rare. Abnormalities of
the tube include pregnancy, infection, torsion, and neoplasm as
well as scarring and obstruction due to other causes.
Pelvic Inlammatory Disease
PID is a common condition that is increasing in frequency. It
consists of inlammation of the endometrium, fallopian tubes,
pelvic peritoneum, and adjacent structures. Typically, the primary
infection is a sexually transmitted disease most oten associated
with gonorrhea and chlamydia, although with previous disruption
of endometrial and tubal tissue due to prior infection, or postsurgical
or postpartum changes, the patient can be infected by her
own vaginal lora. he infection typically spreads by ascent from
the cervix and endometrium. he disease is manifested by tuboovarian
complexes, peritonitis, and abscess formation and is
usually bilateral. Long-term sequelae include chronic pelvic pain,
infertility, and increased risk of ectopic pregnancy.
Less common causes include direct extension from appendiceal,
diverticular, or postsurgical abscesses that have ruptured into
the pelvis, as well as puerperal and postabortion complications.
Hematogenous spread is rare but can occur from tuberculosis.
When caused by direct extension of an adjacent inlammatory
process, it is most oten unilateral. he presence of an intrauterine
device (IUD) increases the risk of PID, although only during a
period of a few weeks following its placement. PID may be
unilateral in patients with IUDs.
Patients usually present clinically with pain, fever, cervical
motion tenderness, and vaginal discharge. A pelvic mass may
be palpated. TVS with color or power Doppler is highly speciic
in the diagnosis of the disease process. 185 However, because the
success of the technique is dependent on the level of operator
expertise and also because early changes can be subtle, TVS
usually only detects complications of the disease. he sonographic
indings may be normal early in the course of PID. 186 Increased
echogenicity of peritoneal fat and indistinctness of the uterus
may be seen early in the disease process but may be diicult to
appreciate. Sonographic indings of the fallopian tubes are the
most speciic and conspicuous indicators of PID (Table 16.2).
TABLE 16.2 Sonographic Findings of
Pelvic Inlammatory Disease
Endometritis
Purulent material
in cul-de-sac
Periovarian
inlammation
Salpingitis
Tubo-ovarian
complex
Tubo-ovarian
abscess
Endometrial thickening
Intracavitary luid
Fluid containing low-level echoes
Enlarged ovaries with multiple cysts
and indistinct margins
Fluid-illed fallopian tube with
(pyosalpinx) or without (hydrosalpinx)
internal echoes
Increased echogenicity of peritoneal
fat
Indistinctness of the uterus
Fusion of inlamed, luid-distended
tube and ovary
Multiloculated mass with variable
septations, irregular margins, and
low-level internal echoes
When imaging a normal appearing fallopian tube, hypervascularity
with color Doppler low within the tubal wall is a valuable
early inding. As the disease progresses, a spectrum of indings
may occur (Fig. 16.24). With inlammation, the tube swells and
endosalpingeal folds thicken. With progressive inlammation and
distal occlusion of the lumen, the tube ills with purulent echogenic
luid, becoming a pyosalpinx. In the presence of a luid-distended
fallopian tube, common indings include wall thickness greater
than 5 mm, incomplete septa seen as the tube folds back on
itself, and thickening of endosalpingeal folds (cogwheel sign). 187,188
Color or power Doppler allows for detection of hyperemia
in the walls and incomplete septi associated with fallopian tube
inlammation (Fig. 16.24B). 189 On TAS, dilated tubes appear as
complex, predominantly cystic masses that are oten indistinguishable
from other adnexal masses. However, TVS allows for
depiction of the luid-illed tube with a tubular shape, somewhat