{"paper_id":"b0170d1e-73ec-4ae2-a239-84fb550dc865","body_text":"CURRENT REFERENCES\nV. Panaritis Æ A. V. Kyriakidis Æ M. Pyrgioti\nA. Apostolopoulos\nColor Doppler sonography of ovarian arteries as a tool in the differential\ndiagnosis of pelvic inflammatory disease and appendicitis\nReceived: 16 August 2004 / Accepted: 28 November 2004 / Published online: 18 February 2005\n/C211Springer-Verlag Berlin / Heidelberg 2005\nAbstract The purpose of this study was to show whether\ncolor Doppler ultrasonography of the ovarian arteries is a\nuseful tool for the differential diagnosis of pelvic inflam-\nmatory disease (PID) and appendicitis. The study in-\ncluded 50 female patients with clinical symptoms of acute\npelvic inflammation and 50 healthy women of the same\nage as a control group. All were examined with color\nDoppler ultrasonography to visualize the internal geni-\ntalia and estimate the blood flow through the ovarian\narteries. Peak systolic velocity (PSV), end diastolic\nvelocity, pulsatility index (DPI), and resistance index were\nmeasured. In the healthy women, ovaries were normal in\nsize, and the parameters of ovarian arterial flow were PSV\n0.30–0.50, systolic/diastolic ratio <0.7, DPI 1.23–1.50. In\n45 of the patients, there was infection and enlargement of\nthe ovaries and/or salpinx, and flow parameters were PSV\n0.40–0.70, systolic/diastolic ratio 0.5–0.8, and DPI 1.40–\n1.96. In five cases the ultrasound image was obscure, and\nflow parameters were similar to those of healthy women.\nThese patients underwent surgery for a diagnosis of\nappendicitis. Our study showed that in cases of diagnostic\ndifferentiation between PID and appendicitis, examina-\ntion with color Doppler ultrasound is very easy and\nuseful. The relatively increased flow parameters in ovarian\narteries direct the diagnosis to PID.\nKeywords Pelvic inflammatory disease Æ Acute\nappendicitis Æ Color Doppler ultrasound\nIntroduction\nAcute pelvic or lower abdominal pain in women is a\nsymptom that commonly leads them to physicians. But\ndetermining the cause of the pain may be difficult\nbecause many diseases present similarly. Pelvic infection\npresents a serious problem for the practicing physician\nand for the radiologist who is called to determine the\norigin and extent of the inflammatory process. Ultra-\nsound has become a valuable primary imaging tool in\nassessing acute pelvic pain in women, both for diagnosis\nand for assessment of complications.\nAim of study\nThis study evaluated the use of color Doppler ultraso-\nnography for differentiating pelvic inflammatory disease\n(PID) from other pelvic infections, mainly appendicitis.\nPatients and methods\nIn this study, carried out over 1 year, we included 50\nfemale patients who came to the emergency setting of\nour hospital with clinical symptoms of acute pelvic\ninfection. Lower or diffuse abdominal pain was their\nmain complaint. Their ages ranged from 13 to 30 years,\nwith a mean age of 24 years. We excluded from our\nstudy those women who were in the first half of their\nmenstrual cycles because in some previous measure-\nments, we found that blood flow in the ovarian arteries\nincreased during estrogen stimulation in the first half of\nthe menstrual cycle. We also excluded women with\nmenstrual cycle problems, such as amenorrhea or luteal\nphase defect; those with previous history of PID; those\nwith polycystic ovaries; and those with positive preg-\nnancy tests. The laboratory exams showed minimally\nelevated values of leukocytes, C-reactive protein, and\nerythrocyte sedimentation rate.\nFor a control group we examined 50 healthy women\nof the same age range with no clinical symptoms and\nwith normal biochemical blood test examinations. These\nvolunteers were selected from subjects visiting our hos-\npital for a screening program/yearly gynecological\nV. Panaritis Æ A. V. Kyriakidis ( &) Æ M. Pyrgioti\nA. Apostolopoulos\nGeneral Hospital of Amfissa, Amfissa Fokida, Greece\nE-mail: alkidi@hotmail.com\nTel.: +30-2265072265\nFax: +30-2265022086\nGynecol Surg (2005) 2: 47–49\nDOI 10.1007/s10397-004-0072-6\n\nexamination who agreed to participate in this study after\nthe purposes, risks, and potential benefits were explained\nto them.\nAll patients and healthy volunteers were examined\nwith color Doppler ultrasonography to visualize the\ninternal genitalia and estimate the blood flow through\nthe ovarian arteries. Peak systolic velocity (PSV), end\ndiastolic velocity, pulsatility index (DPI), and resistance\nindex were measured.\nPatient demographics were taken from the case notes.\nThe two-sample t-test was used to assess differences in\nthe mean values for age. The one-tailed test for pro-\nportions was used to confirm or refute any apparent\ndifferences in proportions (demographics, medical his-\ntory between patients). The chi-square statistic was\nemployed to assess the association between the groups of\ninterest and the incidence of parameters of flow index\nvalues of the ovarian arteries. Values of P<0.05 were\nconsidered significant.\nResults\nIn the healthy female volunteers, ovaries were normal in\nsize, and the parameters of ovarian arterial flow were as\nfollows:\nPSV: 0.30–0.50\nSystolic/diastolic ratio: <0.7\nDPI: 1.23–1.50\nIn 45 of the patients, ultrasound showed infection\nand enlargement of the ovaries or salpinx. Flow\nparameters were as follows:\nPSV: 0.40–0.70\nSystolic/diastolic ratio: 0.5–0.8\nDPI: 1.40–1.96\nIn five cases there was a major diagnostic dilemma\nbetween appendicitis and PID. The boundaries of the\nright ovary were difficult to estimate, and flow parame-\nters were similar to those of healthy women. In those\ndoubtful cases, patients underwent surgery and appen-\ndectomy. Infection of the appendix was found, with its\nlocation following the route of the right ovary.\nWe also observed that by using Doppler examination\nwith stable mechanical parameters, we could easily and\nclearly show the architecture of the ovarian microcir-\nculation when infection was present.\nDiscussion and conclusions\nPelvic inflammatory disease is a major public health\nconcern with significant medical and socioeconomic\nconsequences. It is the most frequent cause of hospital-\nization among reproductive-age women and leads to\ninfertility in about 30% of cases and ectopic pregnancies\nin 50% [ 1–3]. PID includes all the acute or chronic\ninflammations of the salpinx, ovaries, and, often, the\nnearby organs. It is a spectrum of upper genital tract\ninflammatory disorders that may include endometritis,\nsalpingitis, tubo-ovarian abscess, and pelvic peritonitis\n[4]. The risk factors for PID include multiple sexual\npartners, a history of previous sexually transmitted\ninfections/PID [ 4], lack of consistent condom use, and\nthe use of intrauterine devices for contraception.\nThe principal symptom of PID is lower abdominal\npain. Its intensity may vary. Usually it is continuous and\nbilateral with crampy exacerbations, often starting with\nthe onset of menses and following it. Other symptoms\ninclude prolonged or increased menstrual bleeding,\ndysmenorrhea, dysuria, dyspareunia, and vaginal dis-\ncharge. The patient may complain of right upper\nquadrant pain, which may be acute or severe as a result\nof perihepatitis (Fitz-Hugh-Curtis syndrome). Nausea\nand vomiting develop with severe PID, as does a cor-\nresponding peritonitis. Adnexal tenderness, uterine ten-\nderness, and cervical motion tenderness may be noted\nduring physical examination [ 4–7].\nPID is sometimes difficult to diagnose. Its symptoms\nand signs are common for different diseases and vary\nfrom case to case. It can be overdiagnosed, leading to\nmisdiagnosis of PID in healthy women, or underdiag-\nnosed or misdiagnosed when women have other dis-\neases, resulting in delayed appropriate treatment for the\nother conditions, including appendicitis. The differential\ndiagnosis includes irritable bowel disease, diverticulitis,\ninflammatory bowel disease, adhesions after laparos-\ncopy, endometriosis, and acute appendicitis [ 8].\nAcute appendicitis is often misdiagnosed as PID and\nvice versa. Acute appendicitis usually presents with dif-\nfuse abdominal pain around the navel, which thereafter\nis located in the right lower quadrant. It is usually\naccompanied by nausea, vomiting, and a slightly ele-\nvated erythrocyte sedimentation rate, C-reactive protein,\nand leukocytes. Women with appendicitis more fre-\nquently have isolated right lower abdominal pain than\ndo those with PID. On average, women with PID have\npain twice as long as those with appendicitis. Compared\nwith those with appendicitis, patients with PID are sig-\nnificantly less likely to report vomiting [ 9, 10].\nPhysicians face a common diagnostic dilemma when\nfemale patients present with lower abdominal pain.\nEarly diagnosis is very important in order to provide the\nbest treatment for the patient. Transabdominal and\ntransvaginal ultrasound is a helpful diagnostic exami-\nnation. It is possible to view the internal organs of the\npelvic area to see whether the fallopian tubes are\nenlarged or whether an abscess is present. Laparoscopy\nmay confirm the diagnosis [ 11, 12].\nColor Doppler ultrasound is widely used nowadays\nfor assessing differences in blood flow of the ovarian\narteries. It has been used for the diagnosis of luteal\nphase defect, for hemodynamic assessment of PID, and\nfor assessment of women with hypoestrogenic amenor-\nrhea. It has also been used for the differential diagnosis\nof appendicitis and PID [ 13–16].\n48\n\nIn our study, the pulsatility index of the ovarian ar-\ntery was measured and compared with values obtained\nfrom healthy women. One of the major signs of\ninflammation is a change in vascular flow. It is possible\nto detect these changes with the help of transvaginal\ncolor Doppler velocimetry. We detected decreased vas-\ncular resistance in acute infection. Doppler velocity\nwaveforms were quantitated by the pulsatility index. A\nlow-resistance blood flow was found at the margin of the\ninfectious complex. The severity of the infection as\ndetermined by C-reactive protein values was inversely\ncorrelated to the pulsatility index. Angiogenesis is\nresponsible for the increased flow.\nWe conclude that transvaginal color Doppler is a\nuseful additional tool in diagnosing and treating patients\nwith PID. Color Doppler ultrasound of the ovarian ar-\ntery seems to be a reliable, easy, and quick method when\na prompt acute diagnosis is needed.\nThe sonographic criteria consistent with acute\nappendicitis were clearly different from those of acute\ninflammatory disease. More prospective trials are nee-\nded to evaluate the impact of transvaginal color Doppler\nultrasound in the differential diagnosis between appen-\ndicitis and pelvic inflammatory disease.\nReferences\n1. Mathias SD, Kuppermann M, Liberman RF, et al. (1996)\nChronic pelvic pain: prevalence, health-related quality of life\nand economic correlates. Obstet Gynecol 87:321–327\n2. Jamieson DJ, Steege JF (1996) The prevalence of dysmenor-\nrhea, dyspareunia, pelvic pain and irritable bowel syndrome in\nprimary care practices. Obstet Gynecol 87:55–58\n3. Cromwell P, Riser W, Risser J (2000) Prevalence and incidence\nof pelvic inflammatory disease in incarcerated adolescents. Sex\nTransm Dis 28:392–396\n4. Westrom L, Eschenbach D (1998) Pelvic inflammatory disease.\nIn: Holmes K, Sparling P, Mardh P, et al. (eds) Sexually\ntransmitted diseases. McGraw-Hill, New York, pp 783–810\n5. McCormack WM (1994) Pelvic inflammatory disease. N Engl J\nMed 330:115–119\n6. Soper DE (1994) Pelvic inflammatory disease. Infect Dis Clin\nNorth Am 8:821–840\n7. Centers for Disease Control (1998) Guidelines for treatment of\nsexually transmitted diseases. MMWR. Recommendations and\nreports, vol. 47, no. RR-1\n8. Ross J (2001) Pelvic inflammatory disease. BMJ 322:658–659\n9. Molander P, Paavonen J, Sjoberg J, Savelli L, Cacciatore B\n(2002) Transvaginal sonography in the diagnosis of acute\nappendicitis. Ultrasound Obstet Gynecol 20:496–501\n10. Webster DP, Schneider CN, Cheche S, Daar AA, Miller G\n(1993) Differentiating acute appendicitis from pelvic inflam-\nmatory disease in women of childbearing age. Am J Emerg\nMed 11:569–572\n11. Bau A, Arti M (2000) Acute pelvic pain: ultrasound evaluation.\nSemin Ultrasound CT MR 21:78–93\n12. Ghiatas A (2004) The spectrum of pelvic inflammatory disease.\nEur Radiol 14:E184–E192\n13. Papadimitriou A, Kalogirou D, Antoniou G, Petridis N, Kal-\nogirou O, Kalovidouris A (1996) Power Doppler ultrasound: a\npotentially useful alternative in diagnosing pelvic pathologic\nconditions. Clin Exp Gynecol 23:229–232\n14. Pellizzari P, Esposito C, Siliotti F, Marchiori S, Gangemi M\n(2002) Colour Doppler analysis of ovarian and uterine arteries\nin women with hypoestrogenic amenorrhea. Hum Reprod\n17:3208–3212\n15. Alatas C, Aksoy E, Akarsu C, Yakin K, Bahceci M (1996)\nHemodynamic assessment in pelvic inflammatory disease by\ntransvaginal color Doppler ultrasonography. Eur J Obstet\nGynecol Reprod Biol 70:75–78\n16. Kalogirou D, Antoniou G, Botsis D, Kontovardis A, Vitoratos\nN, Giannikos L (1997) Transvaginal Doppler ultrasound with\ncolor flow imaging in the diagnosis of luteal phase defect\n(LPD). Clin Exp Obstet Gynecol 24:95–97\n49","source_license":"CC0","license_restricted":false}