The diagnostic use of magnetic resonance imaging for acute abdominal and pelvic pain in pregnancy

OBJECTIVES

Acute abdomino-pelvic pain in pregnancy represents a diagnostic challenge. In many cases, radiological and laparoscopic diagnostic modalities are hazardous or contraindicated. Magnetic Resonance Imaging (MRI) is not commonly used for this indication and the results are not widely published.

DESIGN AND SETTING

A single-center retrospective observational study.

POPULATION

34 cases of pregnant women with abdomino-pelvic pain who underwent MRI as an additional modality when clinical, laboratory and ultrasound (USS) findings were indeterminate.

METHODS

Case notes were reviewed where pregnant women underwent a MRI investigation for abdominal-pelvic pain. Primary Obstetric indications for an MRI eg placenta accreta were excluded.

MAIN OUTCOME MEASURES

The differential diagnosis after; 1) history and physical examination and 2) with the addition of USS and 3) with the further addition of an MRI were all individually compared to the eventual diagnosis.

RESULTS

The diagnoses reached by MRI corresponded with the final diagnosis in 22 out of 23 cases. In the remaining 11 cases MRI accurately ruled out presence of pathology. MRI was inaccurate in 1 case.

CONCLUSION

The additional use of MRI was more accurate than clinical assessment and USS combined. The accurate exclusion of pathology in 11 cases is particularly significant. MRI should be considered in cases of abdomino-pelvic pain in pregnant women.

Comparison of Emergent and Elective Surgeries of Endometriomas: Is Adnexal Torsion a Concern?

BACKGROUND

When a woman with an endometrioma presents with acute abdominal pain, it is unclear whether ovarian torsion should be suspected.

OBJECTIVES

To compare patient characteristics, imaging results, and surgical management of endometriomas in elective versus emergent surgeries.

METHODS

This retrospective cohort study included women treated at our institution during the period 1990-2015 who presented with histologically verified endometrioma and who underwent either planned surgery or emergent surgery due to suspected adnexal torsion.

RESULTS

Of 225 surgeries performed, 174 were elective and 51 emergent. Patients in the emergent group were significantly younger (33.9 ± 11.1 vs. 39.01 ± 10.9 years, P = 0.004). Abdominal pain was the main complaint of all the emergent surgery patients and the leading complaint in 21% of the elective surgery patients (P < 0.001), with right-sided predominance in both groups. Sonographic parameters were similar in both groups. Bilateral ovarian cysts were noted in 11.7% and 11.0% of emergent and elective patients, respectively (P = 0.87). Laboratory evaluation was notable for a higher white blood cell count and CA125 levels among emergent patients. All patients in the emergent group and 93% of patients in the elective group were managed laparoscopically. No cases of torsion were noted. The rate of intra-pelvic adhesions was similar in both groups (56.8% vs. 66.6%, P = 0.19).

CONCLUSIONS

Endometrioma may present with acute abdominal pain. However, adnexal torsion in these patients is rare. These cases can be managed using a minimally invasive approach, assuming an optimal surgical setting.

Torsion of a uterine leiomyoma - a rare cause of hemoperitoneum; a case report and review of the literature

Uterine leiomyomas are common benign uterine tumors but by contrast, their acute complications are very rare. We present an unusual case of 38-year-old woman that came to the emergency department with acute abdominal pain. The ultrasound revealed hemoperitoneum, a uterus with two intramural fibroids and a tender inhomogeneous pelvic mass that seems to connect with the uterus. Computer tomographic (CT) examination raised the suspicion of a degenerated fibroid and hemoperitoneum. Emergency laparotomy was performed: the hemoperitoneum was determined by a degenerated fundal subserosalfibroid. Myomectomy was subsequently carried out. Even though this condition is extremely rare, every clinician has to bear in mind that acute fibroid complications can be a potential cause of acute abdominal pain that requires immediate surgery. The imagistic tools, ultrasound and CT are extremely helpful for the diagnosis.Due to its relative rarity in the second part of the article we have performed a review of the existing literature regarding the acute complications of fibroid torsion.

[A young woman with acute pain in the lower right abdomen]

A 19-year old woman with acute pain in the lower right quadrant of the abdomen was seen in the emergency room. Because we suspected an anomaly of the appendix, we performed a laparoscopy. We unexpectedly found a torsion of a Hydatid of Morgagni, a stalked cyst of the fallopian tube.

[A pregnant woman with acute abdominal pain]

A 23-year-old pregnant woman presented with acute right-sided abdominal pain and vomiting in the 21st week of gestation. An MRI scan showed an ovarian torsion and a dermoid cyst. On the same day, laproscopy was performed. After removal of the cyst, the pregnancy and the childbirth progressed without complications.

Axial Torsion and Infarction of Meckel\'s Diverticulum in the 3rd Trimester of Pregnancy

Meckel's diverticulum is a congenital anomaly which can become complicated or remain asymptomatic throughout life. During pregnancy, however, diverticulum infection could become a serious complication. Diverticulum necrosis and perforation are complications that increase morbidity in pregnancy, both maternal and fetal. The rarity of the condition and the maternal physiological changes in pregnancy make the diagnosis difficult. We present the case of a Meckel's diverticulum gangrene in third trimester pregnancy, atypical case due to advanced pregnancy where the risk-benefit balance was carefully evaluated on one hand because of the risk of infection associated with expectant management and on the other hand the risk and complications of iatrogenic preterm premature birth. The outcome was favorable for both mother and newborn.

[Isolated fallopian tubal torsion; rare or overlooked?]

Isolated fallopian tubal torsion (IFTT) is a rare cause of lower abdominal pain. It's difficult to diagnose preoperatively due to non-specific clinical symptoms. Furthermore, IFTT is often not considered in the differential diagnosis. Prompt diagnosis is critical, to prevent progression of symptoms and to maintain fertility; therefore, this article discusses diagnostic pitfalls and reports on key imaging features of IFTT that may facilitate preoperative diagnosis. IFTT should be suspected in a female patient with acute lower abdominal pain and a unilateral pelvic mass close to a normal ipsilateral ovary; there may be a history of prior tubal ligation. Specific imaging findings include the sonographic 'whirlpool sign' and absent flow during colour Doppler ultrasound. CT is often performed when the diagnosis remains unclear, but has no clinical consequences. IFTT requires emergency surgical treatment; detorsion without resection can be considered in women who would like to retain potential future fertility, but salpingectomy is often inevitable due to necrosis.

Pisa syndrome in Parkinson's disease: electromyographic quantification of paraspinal and non-paraspinal muscle activity

Patients with Parkinson's disease (PD) and Pisa syndrome (PS) may present tonic dystonic or compensatory (i.e. acting against gravity) hyperactivity in the paraspinal and non-paraspinal muscles. Electromyographic (EMG) activity was measured in nine patients with PD and PS, three with PD without PS, and five healthy controls. Fine-wire intramuscular electrodes were inserted bilaterally into the iliocostalis lumborum (ICL), iliocostalis thoracis (ICT), gluteus medius (GM), and external oblique (EO) muscles. The root mean square (RMS) of the EMG signal was calculated and normalized for each muscle. In stance condition, side-to-side muscle activity comparisons showed a higher RMS only for the contralateral ICL in PD patients with PS (p=0.028). Moreover, with increasing degrees of lateral flexion, the activity of the EO and the ICL muscles progressively increased and decreased, respectively. The present data suggest that contralateral paraspinal muscle activity plays a crucial compensatory role and can be dysfunctional in PD patients with PS.

Colonic obstruction caused by accessory spleen torsion: A rare case report and literature review

RATIONALE

Accessory spleen torsion is a rare cause of the acute abdomen. The complications of accessory spleen torsion, such as intestinal obstruction, are rarer. We herein report a case of colonic obstruction caused by accessory spleen torsion because of the unusual condition.

PATIENT CONCERNS

A 15-year-old patient presented with acute intestinal obstruction with signs of peritoneal irritation. Abdominal computed tomography (CT) and ultrasonography examinations revealed a soft tissue mass in the left midabdomen. Systemic inflammatory response syndrome (SIRS) was observed in this case.

DIAGNOSES

The diagnosis of peritonitis and colonic obstruction secondary to accessory spleen torsion was made. Pathologic examination showed infracted splenic tissue.

INTERVENTIONS

We performed emergency laparotomy and found that accessory spleen torsion pressured against splenic flexure and descending colon, and caused colon obstruction. The patient underwent accessory splenectomy and enteral decompression.

OUTCOMES

At 6 months follow-up, the patient recovered well with perfect digestion.

LESSONS

Accessory spleen torsion and its complications are extremely rare. This entity should be considered in differential diagnosis of acute abdomen. However, in case of acute abdomen with critical clinical situation, emergency surgical intervention is necessary for timely diagnosis and treatment.

Omental torsion: an infrequent cause of abdominal pain

Omental torsion is an infrecuent cause of acute abdomen. It is related to obesity, abdominal surgery and abdominal trauma. Urgent exploratory laparotomy allows diagnosis and prevents complications as intrabdominal abcess. We present CT imaging of a Omenat torsion clinical case.

Bilobate wandering spleen with doble torsion of the vascular pedicle. A case report

INTRODUCTION

Wandering spleen is a rare clinical condition which is often an incidental finding. It is characterized by excessive mobility and displacement of the spleen within the abdomen; although the spleen is usually of normal size it has an elongated vascular pedicle .

CASE STUDY

We present the case of an adult woman who complaining of abdominal pain who was brought to our institution for emergency treatment. She later developed an acute abdomen due to infarction of a wandering spleen caused by double torsion of the vascular pedicle. Emergency splenectomy was performed.

RESULTS

Surgical treatment of a wandering spleen is generally conservative and consists in splenoplexy. In our case, complicated by ischemia leading to irreversible damage of the spleen, splenectomy was the solution.

DISCUSSION

The long vascular pedicle of a migrant spleen is at risk of torsion which can cause irreversible acute ischemia of the spleen. Therefore a timely diagnosis with the use of modern imaging techniques is of primary importance.

CONCLUSIONS

Early interpretation of the symptoms and computed tomography angiography can prevent the complications that result from torsion of the elongated pedicle.

KEY WORDS

Acute abdomen, Bilobate wandering spleen, Splenectomy.

Torsion of a wandering spleen. A rare cause of acute abdomen

Wandering spleen is a rare condition that accounts for less than 0.25% of all indications for splenectomy. It is characterized by ectopic localization of the spleen owing to the lack or weakening of its ligaments. Torsion is the most common complication due to its long pedicle and high mobility, which may result in acute abdomen. We report a case of torsion in a wandering spleen in a 28-year-old male presenting with an acute abdomen that was treated by splenectomy.

The efficiency of endoclips in maintaining the gastrointestinal bleeding-related Dieulafoy's lesion

BACKGROUND

Dieulafoy's lesion (DL) is a relatively uncommon medical condition characterized by a large tortuous arteriole in the submucosa of any part of gastrointestinal (GI) tract wall that bleeds via erosion likely caused in the submucosal surface by protrusion of the pulsatile arteriole. Compared with other endoscopic hemostatic techniques, clipping alone for DL is limited.

AIMS

The aim of the present case series study is to identify common clinical and endoscopic features, rates of occurrence, to review the outcome of endoscopic management of upper GI tract DL, and to illustrate the use and the efficiency of endoclips in maintaining the GI bleeding due to DL.

PATIENTS AND METHODS

This case series was conducted at Department of Gastroenterology, Dıskapı Yıldırım Beyazıt Educational and Research Hospital. The patients who were admitted to the emergency department of Dıskapı Yıldırım Beyazıt Educational and Research Hospital underwent gastrointestinal system (GIS) endoscopy between 2008 and 2013 and were assessed retrospectively. Five cases of GI bleeding related to DL were given endoscopic treatment with hemoclip application. Clinical data, endoscopic findings, and the effects of the therapy were evaluated.

RESULTS

The median number of endoscopic hemoclips application in first endoscopy was 4 (2-9). Rebleeding developed in all patients who had hemoclips applied. Re-endoscopy was performed in three of these patients, which controlled the bleeding. Two patients were transferred to surgery.

CONCLUSIONS

Combination of endoscopic injection and mechanical therapies seems a suitable method for maintaining upper GIS bleeding due to DL. Also, further studies are needed to better define the best endoscopic approach for the treatment of DL.

Small bowel volvulus due to torsion of pedunculated uterine leiomyoma: CT findings

Torsion of a uterine leiomyoma is a rare complication that can be life threatening because of ischemia or necrosis. This condition may also lead to gastrointestinal complications such as obstruction or, more rarely, small bowel volvulus. Its diagnosis is difficult and can be facilitated with the use of computed tomography or magnetic resonance imaging. Treatment is based on emergency surgical resection of the twisted uterine leiomyoma and detorsion of the small bowel volvulus.

Torsion of a Term Uterus

Torsion of the pregnant uterus, at term, is a very rare event in obstetric practice. It is associated with high perinatal mortality. We are reporting a case of uterine torsion, where a booked second gravida with previous lower segment cesarean section underwent an emergency cesarean section due to severe lower abdominal pain, persistent fetal tachycardia and poor Bishop Score. Following delivery of baby and placenta, uterus untwisted on itself through 180 degrees and it was realized that the incision had been made on the posterior wall of the uterus. Bilateral tubal ligation (BTL) was done after proper informed consent. This decision was based on unavailability of data on safety of future pregnancies in patients with both anterior and posterior uterine scars. Efforts need to be made to develop consensus for management of these cases, in future.

Diagnosis of neonatal ovarian torsion: Emphasis on prenatal and postnatal sonographic findings

PURPOSE

Our aim was to retrospectively review the imaging findings of patients with neonatal ovarian torsion, emphasizing prenatal and postnatal sonographic findings.

METHODS

Eleven patients who had had neonatal ovarian torsion diagnosed surgically (n = 9) or clinicoradiologically (n = 2) were enrolled. Prenatal and postnatal sonographic features, including sequential postnatal change, were reviewed. Clinical and pathologic features were also investigated.

RESULTS

All patients except one had a fetal ovarian cyst (mean, 5.3 cm) detected on third-trimester sonography, either simple (n = 6) or complex (n = 4). In all 11 patients, initial postnatal sonography had revealed a complex cyst (mean, 4.7 cm) with intracystic clot or debris, the double-wall sign, a fluid-fluid level, and multiple septation. None of the patients had had symptoms or signs related to the ovarian torsion. Follow-up sonography in seven patients had revealed increased echogenicity of the cyst wall with frequent calcification and a decrease in size of the cyst. In two patients, the interval of the change in cyst position was noted, and autoamputation of the torsed ovary had been surgically confirmed. Serous cystadenoma had been identified in one patient.

CONCLUSIONS

Neonatal ovarian torsion most commonly manifests as an asymptomatic complex cyst on sonography due to torsion of a fetal ovarian cyst. Serial monitoring of a fetal ovarian cyst for its resolution or changes in its appearance is mandatory for making an early diagnosis of torsion. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:290-297, 2016.

Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Omental torsion, a rare cause of acute abdomen

Omental torsion is a rare cause of acute abdominal pain. We report a case of omental torsion in a 7-year-old girl, who presented with right iliac fossa pain. The patient underwent an open appendicectomy, during which a normal appendix was identified and a diagnosis of omental torsion was made. The affected segment of omentum was resected along with the appendix. The patient made an uncomplicated recovery and was discharged on day 1 postoperatively. A normal appendix in the presence of omental torsion is found in 0.1% of all appendicectomies in children. We suggest routine visualisation of the omentum in the presence of a normal appendix during appendicectomy.