Diagnostic ultrasound ( PDFDrive )

588 PART II Abdominal and Pelvic Sonography
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B
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D
FIG. 16.24 Progression of Pelvic Inlammatory Disease. (A) TVS gray-scale and (B) color Doppler images show a normal appearing left
fallopian tube by gray-scale imaging but markedly increased associated vascularity using color Doppler, consistent with salpingitis. (C) TVS image
of a tubo-ovarian complex, a complex mass of fallopian tube and ovary that can still be identiied as separate structures. (D) TVS color Doppler
image of a tubo-ovarian abscess, a cystic, vascular mass containing thick septations in which the fallopian tube and ovary are no longer identiiable.
See also Video 16.11.
folded coniguration, and well-deined walls. 190 he dilated tube
can be distinguished from a luid-illed bowel loop by the lack
of peristalsis. A luid-pus level may occasionally be seen (Fig.
16.24A). Anechoic luid within the tube indicates hydrosalpinx.
In assessing 14 acute and 60 chronic cases of PID, Timor-Tritsch
et al. 188 described three appearances of tubal wall structure: (1)
cogwheel sign, an anechoic cogwheel-shaped structure visible
in the cross section of the tube with thick walls, seen mainly in
acute disease; (2) “beads on a string” sign, hyperechoic mural
nodules measuring 2 to 3 mm on cross section of the luid-illed
distended tube, caused by degenerated and lattened endosalpingeal
fold remnants and seen only in chronic disease; and (3)
incomplete septa, hyperechoic septa that originate as a triangular
protrusion from one of the walls, but do not reach the opposite
wall, seen frequently in both acute and chronic disease and not
discriminatory. Patel et al. 191 found that the presence of a tubular
luid-illed mass with diametrically opposed indentations in the
wall (“waist sign”) had the highest likelihood ratio in discriminating
hydrosalpinx from other adnexal masses (Fig. 16.23B). 191
Other indings include thick tubal walls and bilateral adnexal
masses appearing as small solid masses or thick-walled cystic
masses. 192 Nonspeciic indings of PID include luid in the
endometrial cavity and/or cul-de-sac, and ill-deined ovarian
enlargement oten. Endometrial thickening or luid may indicate
endometritis. Fluid containing low-level echoes may be demonstrated
in the cul-de-sac consistent with purulent material.
With progression of disease, there is exudation of pus from
the distal fallopian tube, periovarian adhesions may form, with
fusion of the inlamed dilated tube and ovary, forming an inlammatory
tubo-ovarian complex (Fig. 16.24C, Video 16.11). he
ovary is still recognizable but cannot be separated from the tube
by applied pressure using the vaginal transducer. 186 Further
progression results in complete breakdown of tubal and ovarian
architecture so that separate structures are no longer identiied
and there is obscuration of the posterior and lateral margins of
the uterus resulting in a tubo-ovarian abscess (Fig. 16.24D).
Sonographically, this appears as a multiloculated mass with
incomplete septations, irregular margins, and low-level internal