{"paper_id":"82ecf102-09b4-4228-9e7c-3e5438cece79","body_text":"International Journal of Science and \nResearch (IJSR)\n \nISSN: 2319\n-\n7064\n \nSJIF (2019): 7.583\n \nVolume 10 Issue 2, February 2021\n \nwww.ijsr.net\n \nLicensed Under Creative Commons Attribution \nCC BY\n \nRole of \nUSG \nand \nMDCT \nin the Evaluation of Pelvic \nPain in Women of Reproductive Age Group\n \n \nDr Mohd Arif Khan\n1\n, Dr Anchal Gupta\n2\n, Dr Aditya Verma\n3\n \n \n \n1.\n \nIntroduction\n \n \nAcute pelvic and/or lower abdominal pain in\n \nnonpregnant\n  \nwomen of reproductive age is an extremely common \npresentation to emergency d\nepartments, urgent care centers \nand outpatient office practices. Approximately\n \n1.4 million \ngynecologic visits were made to emergency departments \nannually, for an average\n \nannual rate of 24.3 visits per \n100 \nwomen between the ages 15 to 44 years. Acute pelvic pain \ngenerally implies pain that is of less than 3 months duration \nin a toxic\n, ill appearing and unstable pat\nient, or \nchronic pain \nthat is worsening. When a female in the  reproductive age \npresents with acute pelvic and/or lower abdominal pain, the \nfirst \ndiagnoses to consider are those \nthat are life threatening \nand would require ur\ngent and/or emergent surgical \nintervention. Because the differential\n \ndiagnosis of acute \npelvic pa\nin in the nonpregnant female of \nreproductive age \nincludes many different organ systems (i.e. gastrointestinal, \ngynecological, urological, vascular, etc.) a cos\nt\n-\neffective and \nefficient strategy, such a ultrasound need to be employed. It \nis essential in the assessment of pelvic pain in women of \nreproductive age to initially exclude pregnancy via urine \nand/or serum hCG. The diagnosis of pelvic pain is a \ncomposite \npicture (history, physical examin\nation and \ninvestigations). No single fact or observation elicits the \ndiagnosis. When evaluating pelvic pain, as with any clinical \npresentation, it is important to ask about the onset, location, \nquality, severity, radiation,\n \nduration, aggravating and \nalleviating factors and any temporal changes of the pain \novertime. In addition, one must ask about associated\n \nsymptoms, such as nausea, vomiting, diarrhea, fever, flank \npain, dysuria, hematuria, pyuria, frequency, urgency, vagina\nl \nbleeding and vaginal discharge. The medical history should \nfocus on the patient’s last me\nnstrual period, age of onset of \nmenarche, sexual history, history of sexually transmitted \ndiseases and a complete obstetric history. The physical \nexamination should \nconcentrate on the vital signs, \nabdominal and pelvic examination.\n \n \n2.\n \nMaterials and Methods\n \n \nThis prospective study was carried out in the Post Graduate \nDepartment of Radio\n-\ndiagnosis and Imaging over a period \nof one year.\n \n \nUSG\n \nAn adequate history was elicited, followed by a focused \nclinical examination and relevant ancillary investigations of \nevery patient was done prior to USG. A brief account of the \nprocedure was explained to the patient with the emphasis on \nreassuring them pr\nior to the procedure. Informed and written \nconsent was taken from\n \nthe patients/attendants. \nUltrasound \nwas performed with patient in supine position and using \nSamsung SonoAce R7 machine in the same setting with a \ncurvilinear (3\n-\n5 MHz) and linear array multi\n \nfrequency (7\n-\n10 MHz) transducer.\n \nAn attempt was made to compare USG \nfindings with clinical and operative findings wherever \nsurgery was done.\n \n \nMDCT\n \nThe study was performed with 256\n-\nslice MDCT Somatom \nDefinition Flash (Siemens Healthcare, Forchheim, \nGermany\n) with 120 KVp and 150\n-\n350mAs and pitch of 0.6 . \nImages was reconstructed at a thickness of 1 mm and large \nFOV in cranio\n-\ncaudal direction from the level of the \nXiphisternum to pubic\n-\nsymphysis before and after \nadministration of oral (10\n-\n20ml water soluble c\nontrast in \n500\n-\n1000ml distilled water) and intravenous non\n-\nionic \niodinated contrast of 1.5\n-\n2ml/kg dose @ 3\n-\n4ml/s. All images \nwere viewed in a range of soft tissue window setting. Images \nwas reformatted in sagittal and coronal planes for analysis. \nAn attemp\nt was also be made to compare MDCT findings \nwith clinical, ultrasound and operative findings wherever \nsurgery was done.\n \n \n3.\n \nObservation \na\nnd Results\n \n \nA total of 50 patients were included in study with 21\n-\n40 \nyears age group, who had undergone USG for acute pelvic \npain. Besides pelvic pain the associated symptoms in the \nstudy group were fever, vomiting, anorexia, weight loss and \ndiarrhea. Acute appendicit\nis, Hemorrhagic cysts, ovarian \ndermoid, ovarian torsion, endometriotic cyst and urolithiasis \nwere the common\nly seen pathologies.\n \n \nTable 1: \nShowing the Age Distribution in the Study \nPopulation\n \nAge Groups \n(Years)\n \nFrequency\n \nPercentage \n(%)\n \n0 to 10\n \n-\n \n \n11 to \n20\n \n12\n \n24%\n \n21 to 30\n \n10\n \n20%\n \n31 to 40\n \n28\n \n56%\n \n \nTable 2: \nClinical Features Of Patients\n \nS. N\no\n \nClinical Features\n \nNo. of Patients\n \nPercentage (%)\n \n1\n \nAbdominal pain\n \n50\n \n100\n \n2\n \nFever\n \n05\n \n10\n \n3\n \nVomiting\n \n07\n \n14\n \n4\n \nAnorexia\n \n05\n \n10\n \n6\n \nDiarrhea\n \n02\n \n4\n \n \nTable\n \n3: \nVarious \npathologies detected are tabulated.\n \nNo\n \nPathology\n \nFrequency\n \nPercentage (%)\n \n1\n \nAcute appendicitis\n \n3\n \n6%\n \n2\n \nAppendicular lump\n \n2\n \n4\n%\n \n3\n \nEctopic pregnancy\n \n4\n \n8\n%\n \n4\n \nOvarian dermoid\n \n8\n \n16\n%\n \n5\n \nUrolithiasis\n \n5\n \n10\n%\n \n6\n \nHemorrhagic cyst\n \n8\n \n16\n%\n \nPaper ID: SR21206220236\nDOI: 10.21275/SR21206220236\n497 \n\nInternational Journal of Science and \nResearch (IJSR)\n \nISSN: 2319\n-\n7064\n \nSJIF (2019): 7.583\n \nVolume 10 Issue 2, February 2021\n \nwww.ijsr.net\n \nLicensed Under Creative Commons Attribution \nCC BY\n \n7\n \nEndometriotic cyst\n \n6\n \n12\n%\n \n8\n \nOvarian torsion\n \n5\n \n10\n%\n \n9\n \nPID\n \n5\n \n10%\n \n \nTable 4: \nFindings in Appendicitis\n \n4 A. USG \nFindings\n \nS.N\no\n \nFindings\n \nNo. of Cases\n \n01.\n \nNon\n-\nvisualize appendix\n \n1\n \n02.\n \nNon compressible, aperistaltic tubular blind \nended structure with diameter>6 mm\n \n2\n \n03.\n \nProbe tenderness\n \n3\n \n04.\n \nPeriappendiceal echogenic fat.\n \n2\n \n \n4 B. MDCT \nFindings\n \n1\n \nThickened  enhancing appendix\n \n3\n \n2\n \nAppendicolith\n \n1\n \n3\n \nPeriappendiceal stranding\n \n3\n \n4\n \nThick walled caecum and terminal ileum.\n \n2\n \n5\n \nFocal perforation\n \n0\n \n \nTable \n5: \nFindings in Ovarian Dermoid\n \n5A. USG \nFindings\n \nS. NO\n \nFindings\n \nN\no\n \nof\n \nCases\n \n1.\n \nComplex cystic mass\n \n01\n \n2.\n \nDermoid plug\n \n05\n \n3.\n \nFat\n-\nfluid level\n \n02\n \n4.\n \nMultiple thin echogenic bands within mass\n \n00\n \n \n5 B.\n \nMDCT \nFindings\n \nS.NO\n \nFindings\n \nNo. of Cases\n \n1.\n \nCystic area of fat attenuation\n \n07\n \n2.\n \nNon\n-\nenhancing soft tissue component\n \n07\n \n3.\n \nCentral calcification\n \n08\n \n \nTable \n6: \nFindings in ectopic pregnancy\n \nUSG \nFindings\n \nS. NO\n \nFindings\n \nNO. of Cases\n \n1.\n \nwell defined gestational sac with yolk sac, \nseparate from ovary and uterus\n \n1\n \n2.\n \nHeterogenous adnexal\n \nmass\n \n03\n \n3.\n \nPelvic hematoma\n \n02\n \n4.\n \nHemoperitoneum\n \n03\n \n \nTable \n7: \nFindings in Hemorrhagic Cyst\n \n7 A. USG \nFindings\n \nS. No\n \nFindings\n \nNo. of Cases\n \n1\n \nCystic area, internal septation\n \n3\n \n2\n \nFibrin strands\n \n3\n \n3\n \nOrganised clot\n \n2\n \n \n7 B. MDCT Findings\n \nS. NO\n \nFindings\n \nNo.\n \nOf Cases\n \n1\n \nCyst with internal high density\n \n5\n \n2\n \nFluid\n-\nfluid level\n \n3\n \n \nTable 8: \nFindings i\nn Endometriosis\n \nUSG \nFindings\n \nS. NO\n \nFindings\n \nNo. Of Cases\n \n01\n \nMulti\n-\nloculated cystic area with \nhomogenous ground glass echos.\n \n03\n \n02\n \nEchogenic\n \nfoci of calcification within \nwall.\n \n03\n \n \n \n \nTable \n9: \nFindings in Torsion \nUSG \nFindings\n \nS. NO\n \nFindings\n \nNo. of \nCases\n \n1\n \nEnlarged, edematous ovary with peripherially \narranged cystic area, deviation of u\nterus, no \nflow on color doppler\n \nwith minimal \nsurrounding free fluid.\n \n5\n \n \n4.\n \nDiscussion\n \n \nOne of the most common gynecological causes of acute \npelvic pain is ruptured or hemorrhagic corpus luteum\n \ncyst. A \nhemorrhagic ovarian cyst is a cyst that is filled with blood, \nwhich usually occurs when a blood vessel breaks into the \ncyst. Pain from a hemorrhagic cyst is probably due to \nstretching of the ovarian capsule, as opposed to pain from \novarian cyst ru\npture which is due to peritoneal irritation. \nSimilar to ovarian torsion and ruptured ovarian cysts, \npatients with a hemorrhagic cyst also present with unilateral \nlower abdominal and/or pelvic pain associated with nausea, \nvomiting and/or vaginal bleeding. B\necause hemorrhagic cyst \nevolve in different stages, fresh blood on the ultrasound \ninitially appears anechoic, later transforming to a blood clot\n \n(echogenic content with thin septations) and finally \nresolving, the echogenicity of the hemorrhagic cyst \ndimini\nshes as the red blood cell undergoes hemolysis. The \ntypical appearance on ultrasound is that of an enlarged ovary \ncontaining multiple echogenic areas (representing blood \nclots) in a reticular pattern due to clot (representing fibrin \nstrands, not tissue sep\ntati\nons) retraction. In our study 8\n \npatients had hemorrhagic cysts. USG revealed a complex \novarian lesion with numerous thin septations. Color Doppler \nreveals peripheral vascularity. Pulsed Doppler waveform \nanalysis demonstrates low to moderate impedance t\no blood \nflow signals, typical for luteal conversion.\n \n \nDermoid cysts (mature cystic teratoma) are the commonest \ngerm cell neoplasm and in some series the most commonly \nexcised ovarian tumour. They are composed of tissue from \nat least two of the germ cell la\nyers and often contain hair, \nsebum and teeth. These tumours show a wide range of \nultrasonic appearances because of their variable \ncomposition. On account of this they may mimic a variety of \nother pelvic masses. However, the ultrasonic appearance can \nbe dis\ntinctive, and a number of sonographic signs \ncharacteristic of dermoid cysts have been described. In our \nstudy of 8 patients typical appearances include a shadowing \nechodensity or dermoid plug; diffuse or regional high \namplitude echoes; the tip of the icebe\nrg sign; dermoid mesh; \nfat\n–\nfluid levels and intracystic floating balls.\n \n \nEndometriosis is a gynaecological condition in which the \nendometrial cells (lining cells) of the uterus (womb) grow in \nplaces outside the uterus. Cystic endometriosis or \nendometrioma \nis a type of cyst formed when endometrial \ntissue grows in the ovaries.\n \n \nIt affects women during the reproductive years and may \ncause chronic pelvic pain associated with menstruation. The \novaries are involved in approximately 75% of patients with \nendometrio\nsis. In our study 6 patients had endometriotic cyst \nas cause of pelvic pain. On ultrasound endometrioma can be \nvariable but the great majority (about 95%) of patients \nPaper ID: SR21206220236\nDOI: 10.21275/SR21206220236\n498 \n\nInternational Journal of Science and \nResearch (IJSR)\n \nISSN: 2319\n-\n7064\n \nSJIF (2019): 7.583\n \nVolume 10 Issue 2, February 2021\n \nwww.ijsr.net\n \nLicensed Under Creative Commons Attribution \nCC BY\n \npresent with a classic homogeneous, hypoechoic cyst with \ndiffuse low level echoes. Rarely\n \nit is anechoic, mimicking a \nfunctional ovarian cyst.\n \nEndometriomas can be multilocular \nand have thin or even thick septations.\n \n \nPelvic inflammatory disease: Pelvic inflammatory disease \nrefers to the infection of the upper female genital tract \n(uterus, fal\nlopian tubes, oviducts and ovaries) caused by \nascending spread of bacteria from menstruating female who \nhas had multiple sexual partners and does not use barrier \ncontraception and complains of pelvic pain and/or lower \nabdominal pain with vaginal discharge.\n \n5 patients had PID \nas a cause of acute pelvic pain which on Sonography \nshowed enlarged ovaries and poorly defined margins of the \npelvic organs. In acute salpingitis, the fallopian tube is \nthickened and hypoechoic. It can be differentiated from \nacute appen\ndicitis on transvaginal US by finding the \nconnecting organ to the tubular structure. With salpingitis, \nthe structure can be traced to uterus. Another way to \ndifferentiate these two entities is by pattern recognition. If \nthe structure is multilayered it cou\nld be consistent with \nappendicitis, whereas a single layered structure would be \nmore consistent with salpingitis.\n \n \nAcute cystitis: Urinary tract infections encompass both the \nlower (cystitis) and upper urinary tracts (pyelonephritis), \nThe main organisms re\nsponsible for both upper and lower \nurinary tract infections are E. coli. Other organisms include \nProteus species, S. saprophyticus, Klebsiella species and \nEnterococcus faecalis. Classically, patients present with \ndysuria, urgency, frequency, lower abdomina\nl and/or pelvic \ndiscomfort. The pain may be referred to the right and left \nlower quadrants and flanks. Many patients may have \nsuprapubic tenderness and/or costovertebral tenderness. In \nmost cases, the diagnosis is based on clinical features along \nwith urin\ne analysis and cultures. These symptoms are very \nsimilar to all the previous cases. Pelvic inflammatory \ndisease, vaginitis or cervicitis may also cause dysuria. In our \nstudy there were 4 patients who presented with above said \ncomplaints. Ultrasound has the\n \nadvantage of evaluating the \nspectrum of pelvic pathologies. A transabdominal ultrasound \nfor this case revealed a urinary bladder filled with sludge \nand mobile echoes. Antimicrobial treatment is directed to \nthe most prevalent microorganisms.\n \n \nOvarian torsi\non: Total of 5 patients had ovarian torsion as \ncause of acute pelvic pain. On USG ovary is usually \nenlarged and hypoechoic, with peripherally stacked debris \ncontaining follicles. Color Doppler US is invaluable in the \ndiagnosis of this entity and in differe\nntiating it from acute \noophoritis. If the torsion is complete there is no venous or \narterial flow within the ovary on color Doppler examination. \nThe Doppler waveform may show reversal of flow in the \novarian pedicle. If the torsion is incomplete, color Dopp\nler \nexamination may show highly resistive flow within the \novary. Primary ovarian torsion occurs in adolescents, \nwhereas in females past adolescence, torsion usually \ninvolves ovaries containing large cysts or masses.\n \n \nAcute Appendicitis and Appendicular Lum\np: Total of 5 \npatients had appendicular inflammation as the cause of \npelvic pain. Most common sonographic feature were (a) \nprobe tenderness (b) non\n-\ncompressible, aperistaltic tubular \nblind gut loop with thickness more than 6 mm, (c) \nperiappendiceal fat inf\nlammation.\n \n \nUrolithiasis: 5 of the patients had lower ureteric calculi and \nupstream hydronephrosis as the cause for their pain. \nUltrasound could demonstrate hydroureteronephrosis and \nureteri\nc calculus.\n \n \n5.\n \nConclusion\n \n \nAcute pelvic and/or lowe\nr abdominal pain in nonpregnant \nwomen of reproduc\ntive age is an extremely common \npresentation to emergency departmen\nts, urgent care centers \nand outpatient office practices. Acute pelvic pain includes a \nbroad spectrum of clinical entities that range from be\nnign \nself\n-\nlimited disorders to illnesses associated with high \nmorbidity, requiring the clinician to make an urgent \ntherapeutic decision. Prompt diagnosis is essential to \nminimize morbidity, which remains substantial if a \ncomplication\n \noccurs.USG offers a pr\nompt beside safe and \npainless method for evaluation of cause of pain.\n \nMDCT \noffers an unparalled clarity\n,\n \nsensitivity and specificity in \ndiagnosing and ruling out certain causes of pelvic pain.\n \nPaper ID: SR21206220236\nDOI: 10.21275/SR21206220236\n499","source_license":"CC0","license_restricted":false}