DOI: 10.1148/rg.273065116
MR Imaging of Acute Right Lower Quadrant Pain in Pregnant and Nonpregnant Patients1
Ivan Pedrosa, MD,
Eric A. Zeikus, MD,
Deborah Levine, MD, and
Neil M. Rofsky, MD
1 From the Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215. Recipient of a Cum Laude award for an education exhibit at the 2005 RSNA Annual Meeting. Received June 7, 2006; revision requested July 19 and received September 13; accepted September 14. N.M.R. receives research support from GE Healthcare (Waukesha, Wis), is on the advisory board of Berlex Laboratories (Wayne, NJ), and is a consultant to CAD Sciences (White Plains, NY); all other authors have no financial relationships to disclose.
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Figure 1. Normal appendix in a 48-year-old woman with pelvic pain. Coronal T2-weighted single-shot fast SE image of the upper pelvis shows the cecum (C) and bladder (B). The normal appendix (arrows) is clearly delineated as a blind-ending tubular structure arising off the base of the cecum. In the absence of oral contrast material, the normal appendix demonstrates signal intensity similar to that of the bowel wall on single-shot fast SE images.
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Figure 2a. Usefulness of oral contrast material and TOF imaging in evaluation of the normal appendix during pregnancy in a 31-year-old woman who was 30 weeks pregnant and had RLQ pain and nausea. (a) Axial T2-weighted single-shot fast SE image of the gravid abdomen shows the cecum (C) and terminal ileum (*). A possible normal appendix (arrow) is seen posterior to the cecum. However, other tubular hypointense structures (arrowheads) with a similar appearance are seen medial to the psoas muscle. (b) Axial TOF GRE image obtained at the same level shows the characteristic enlargement and decreased signal intensity of the appendix (arrow), the so-called blooming effect, which is caused by the susceptibility effect of air or the iron-based oral contrast medium within its lumen. Note the same effect in the cecum (C) and terminal ileum (*). This phenomenon virtually excludes appendicitis. TOF images are also essential in differentiating the common periovarian varices (arrowheads) with very high signal intensity from the hypointense appendix; this distinction cannot be made on the single-shot fast SE images alone.
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Figure 2b. Usefulness of oral contrast material and TOF imaging in evaluation of the normal appendix during pregnancy in a 31-year-old woman who was 30 weeks pregnant and had RLQ pain and nausea. (a) Axial T2-weighted single-shot fast SE image of the gravid abdomen shows the cecum (C) and terminal ileum (*). A possible normal appendix (arrow) is seen posterior to the cecum. However, other tubular hypointense structures (arrowheads) with a similar appearance are seen medial to the psoas muscle. (b) Axial TOF GRE image obtained at the same level shows the characteristic enlargement and decreased signal intensity of the appendix (arrow), the so-called blooming effect, which is caused by the susceptibility effect of air or the iron-based oral contrast medium within its lumen. Note the same effect in the cecum (C) and terminal ileum (*). This phenomenon virtually excludes appendicitis. TOF images are also essential in differentiating the common periovarian varices (arrowheads) with very high signal intensity from the hypointense appendix; this distinction cannot be made on the single-shot fast SE images alone.
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Figure 3. Appendicitis in a 33-year-old woman who was 17 weeks pregnant and had RLQ pain and fever. Axial T2-weighted single-shot fast SE image of the lower abdomen shows the cecum (C) and terminal ileum (TI). The appendix (arrow) is identified posterior to the cecum. The appendix is enlarged (8-mm diameter) and thick walled and its lumen is filled with high-signal-intensity fluid, whereas the cecum and terminal ileum are completely filled with negative oral contrast material. The MR imaging findings were consistent with early appendicitis, which was confirmed at surgery.
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Figure 4a. Mild acute appendicitis in a 20-year-old woman who was 10 weeks pregnant and had RLQ pain. C = cecum. (a) Sagittal T2-weighted single-shot fast SE image of the right lower abdomen shows the cecum tilted superiorly. Located just beneath the cecum is the appendix (arrows). Note that the cecum is completely filled with negative contrast material, as opposed to the high-signal-intensity lumen of the appendix. The appendiceal wall is visible, but the appendix is not dilated. (b) Sagittal fat-saturated T2-weighted single-shot fast SE image obtained at the same level shows increased signal intensity in the periappendiceal fat (arrows), a finding that confirms the presence of acute inflammation. Mild acute appendicitis was found at surgery and pathologic analysis.
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Figure 4b. Mild acute appendicitis in a 20-year-old woman who was 10 weeks pregnant and had RLQ pain. C = cecum. (a) Sagittal T2-weighted single-shot fast SE image of the right lower abdomen shows the cecum tilted superiorly. Located just beneath the cecum is the appendix (arrows). Note that the cecum is completely filled with negative contrast material, as opposed to the high-signal-intensity lumen of the appendix. The appendiceal wall is visible, but the appendix is not dilated. (b) Sagittal fat-saturated T2-weighted single-shot fast SE image obtained at the same level shows increased signal intensity in the periappendiceal fat (arrows), a finding that confirms the presence of acute inflammation. Mild acute appendicitis was found at surgery and pathologic analysis.
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Figure 5. Acute appendicitis in a 25-year-old woman who was 16 weeks pregnant and had RLQ pain and leukocytosis. Axial T2-weighted single-shot fast SE image of the right midabdomen shows the appendix (black arrowhead), which is curved medially, arising from the base of the cecum (C). Note the high signal intensity within the appendiceal lumen and that the appendix is dilated. A rounded area of low signal intensity (arrow) in the proximal appendix is noted; this area represents an appendicolith. Periappendiceal fat stranding is seen as a bandlike area of high signal intensity (white arrowheads) in the adjacent fat. The MR imaging findings were consistent with acute appendicitis, which was confirmed at surgery and pathologic analysis.
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Figure 6. Appendiceal phlegmon in a 29-year-old woman who was 27 weeks pregnant and had RLQ pain. Sagittal T2-weighted single-shot fast SE image of the right hemiabdomen shows a heterogeneous moderately hyperintense mass (arrows) in the RLQ with mass effect on the cecum (C), an appearance consistent with a phlegmon. Note that the right ovary (arrowhead) is displaced anteriorly. The patient was treated with intravenous antibiotics, and follow-up MR imaging at 32 weeks showed resolution of the phlegmon with a persistent abnormally dilated appendix. The patient underwent cesarean section and appendectomy, which confirmed the diagnosis of perforated appendicitis.
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Figure 7a. Ruptured appendiceal mucocele in a 72-year-old man with right-sided pelvic pain and abnormal appearance of the appendix at prior CT performed at another institution. (a) Coronal T2-weighted single-shot fast SE image shows the cecum (C), normal terminal ileum (black arrowheads), and bladder (B). A thick-walled appendix (arrow) is present, surrounded by an irregularly shaped fluid collection (white arrowheads). (b) Axial T2-weighted fast SE image shows cystic dilatation of the appendiceal tip (*) and periappendiceal free fluid (arrowheads), findings suggestive of a ruptured appendiceal mucocele. A ruptured mucocele secondary to an appendiceal cystadenoma was found at surgery and pathologic analysis.
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Figure 7b. Ruptured appendiceal mucocele in a 72-year-old man with right-sided pelvic pain and abnormal appearance of the appendix at prior CT performed at another institution. (a) Coronal T2-weighted single-shot fast SE image shows the cecum (C), normal terminal ileum (black arrowheads), and bladder (B). A thick-walled appendix (arrow) is present, surrounded by an irregularly shaped fluid collection (white arrowheads). (b) Axial T2-weighted fast SE image shows cystic dilatation of the appendiceal tip (*) and periappendiceal free fluid (arrowheads), findings suggestive of a ruptured appendiceal mucocele. A ruptured mucocele secondary to an appendiceal cystadenoma was found at surgery and pathologic analysis.
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Figure 8a. Crohn disease in a 26-year-old woman with RLQ pain and fever. (a) Axial T2-weighted fast SE image of the lower abdomen shows marked mural thickening in the distal ileum (arrows) with a layer of increased signal intensity suggestive of submucosal edema. There is prominence, dilatation, and tortuosity of the vasa recta coursing through proliferative mesenteric fat, the comb sign (arrowheads). (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image obtained at the same level shows marked mural enhancement (arrows) in the abnormal loop of distal ileum. Linear areas of low signal intensity in the wall correspond to the edema in the bowel wall. The comb sign is better appreciated with gadolinium contrast material (arrowheads). These findings are consistent with an acute flare of Crohn disease.
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Figure 8b. Crohn disease in a 26-year-old woman with RLQ pain and fever. (a) Axial T2-weighted fast SE image of the lower abdomen shows marked mural thickening in the distal ileum (arrows) with a layer of increased signal intensity suggestive of submucosal edema. There is prominence, dilatation, and tortuosity of the vasa recta coursing through proliferative mesenteric fat, the comb sign (arrowheads). (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image obtained at the same level shows marked mural enhancement (arrows) in the abnormal loop of distal ileum. Linear areas of low signal intensity in the wall correspond to the edema in the bowel wall. The comb sign is better appreciated with gadolinium contrast material (arrowheads). These findings are consistent with an acute flare of Crohn disease.
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Figure 9a. Abscess in a 59-year-old man with a history of Crohn disease who presented with fever, chills, and lower abdominal pain. (a) Axial T2-weighted fast SE image shows a thick-walled fluid collection (arrows) in the left hemipelvis, adjacent to the sigmoid colon (arrowheads). (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image obtained during the delayed venous phase shows peripheral rim and septal enhancement of the fluid collection (arrows). The sigmoid colon is again visualized (arrowheads). The diagnosis of an abscess related to Crohn disease was confirmed with percutaneous drainage of the fluid collection.
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Figure 9b. Abscess in a 59-year-old man with a history of Crohn disease who presented with fever, chills, and lower abdominal pain. (a) Axial T2-weighted fast SE image shows a thick-walled fluid collection (arrows) in the left hemipelvis, adjacent to the sigmoid colon (arrowheads). (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image obtained during the delayed venous phase shows peripheral rim and septal enhancement of the fluid collection (arrows). The sigmoid colon is again visualized (arrowheads). The diagnosis of an abscess related to Crohn disease was confirmed with percutaneous drainage of the fluid collection.
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Figure 10a. Small bowel obstruction in a 34-year-old woman with a history of ulcerative colitis and prior total colectomy who was 19 weeks pregnant and presented with nausea, vomiting, and abdominal pain. (a) Coronal T2-weighted single-shot fast SE image of the abdomen and pelvis shows the gravid uterus with the placenta (P). There is diffuse dilatation of fluid-filled loops of small bowel. Well-circumscribed areas of high signal intensity surround the bowel (arrows) and conform to the borders of the abdominal wall, a finding indicative of free fluid. (b) Sagittal T2-weighted single-shot fast SE image of the RLQ shows the dilated, fluid-filled small bowel loops. The patient’s ostomy (large arrowhead) is collapsed, and the end ileal loop (arrow) tapers abruptly to the ostomy; these findings indicate the transition point of the small bowel obstruction caused by stenosis at the level of the os-tomy. The free fluid is seen beneath the small bowel loops (small arrowhead). The small bowel obstruction was relieved after placement of a catheter and dilation of the ostomy.
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Figure 10b. Small bowel obstruction in a 34-year-old woman with a history of ulcerative colitis and prior total colectomy who was 19 weeks pregnant and presented with nausea, vomiting, and abdominal pain. (a) Coronal T2-weighted single-shot fast SE image of the abdomen and pelvis shows the gravid uterus with the placenta (P). There is diffuse dilatation of fluid-filled loops of small bowel. Well-circumscribed areas of high signal intensity surround the bowel (arrows) and conform to the borders of the abdominal wall, a finding indicative of free fluid. (b) Sagittal T2-weighted single-shot fast SE image of the RLQ shows the dilated, fluid-filled small bowel loops. The patient’s ostomy (large arrowhead) is collapsed, and the end ileal loop (arrow) tapers abruptly to the ostomy; these findings indicate the transition point of the small bowel obstruction caused by stenosis at the level of the ostomy. The free fluid is seen beneath the small bowel loops (small arrowhead). The small bowel obstruction was relieved after placement of a catheter and dilation of the ostomy.
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Figure 11a. Cecal pneumatosis in a 47-year-old diabetic woman with fever and abdominal pain 2 months after pancreatic transplantation. She had undergone renal transplantation 5 years before this admission. (a) Axial T2-weighted single-shot fast SE image of the lower abdomen shows an air-fluid level in the lumen of the cecum (black arrowhead). A curvilinear area of low signal intensity that conforms to the wall of the cecum (arrows) represents pneumatosis. Part of the cecal wall appears as a thin line of intermediate signal intensity (white arrowhead) that separates the luminal air from the pneumatosis. (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image of the upper abdomen, obtained during the portal venous phase, shows lack of signal within the left portal vein (arrow) due to air in the portal vein. (c) Unenhanced CT scan shows the cecal pneumatosis (arrows) and cecal wall thickening (arrowhead); CT also showed the air in the left portal vein. At surgery, a perforated diverticulum was found in the cecum.
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Figure 11b. Cecal pneumatosis in a 47-year-old diabetic woman with fever and abdominal pain 2 months after pancreatic transplantation. She had undergone renal transplantation 5 years before this admission. (a) Axial T2-weighted single-shot fast SE image of the lower abdomen shows an air-fluid level in the lumen of the cecum (black arrowhead). A curvilinear area of low signal intensity that conforms to the wall of the cecum (arrows) represents pneumatosis. Part of the cecal wall appears as a thin line of intermediate signal intensity (white arrowhead) that separates the luminal air from the pneumatosis. (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image of the upper abdomen, obtained during the portal venous phase, shows lack of signal within the left portal vein (arrow) due to air in the portal vein. (c) Unenhanced CT scan shows the cecal pneumatosis (arrows) and cecal wall thickening (arrowhead); CT also showed the air in the left portal vein. At surgery, a perforated diverticulum was found in the cecum.
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Figure 11c. Cecal pneumatosis in a 47-year-old diabetic woman with fever and abdominal pain 2 months after pancreatic transplantation. She had undergone renal transplantation 5 years before this admission. (a) Axial T2-weighted single-shot fast SE image of the lower abdomen shows an air-fluid level in the lumen of the cecum (black arrowhead). A curvilinear area of low signal intensity that conforms to the wall of the cecum (arrows) represents pneumatosis. Part of the cecal wall appears as a thin line of intermediate signal intensity (white arrowhead) that separates the luminal air from the pneumatosis. (b) Axial gadolinium-enhanced 3D fat-saturated T1-weighted GRE image of the upper abdomen, obtained during the portal venous phase, shows lack of signal within the left portal vein (arrow) due to air in the portal vein. (c) Unenhanced CT scan shows the cecal pneumatosis (arrows) and cecal wall thickening (arrowhead); CT also showed the air in the left portal vein. At surgery, a perforated diverticulum was found in the cecum.
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Figure 12a. Endometriosis in a 37-year-old woman with RLQ pain and a right adnexal mass at US. (a) Axial T1-weighted GRE image shows two lesions (arrows) with homogeneous high signal intensity in the pelvis. (b) Sagittal T2-weighted fast SE image shows heterogeneous decreased or low signal intensity (shading) in the two lesions (arrows), which are located immediately superior to the uterus (U). Gadolinium-enhanced MR imaging showed no enhancement within the lesions. Endometriomas were confirmed at surgery and pathologic analysis.
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Figure 12b. Endometriosis in a 37-year-old woman with RLQ pain and a right adnexal mass at US. (a) Axial T1-weighted GRE image shows two lesions (arrows) with homogeneous high signal intensity in the pelvis. (b) Sagittal T2-weighted fast SE image shows heterogeneous decreased or low signal intensity (shading) in the two lesions (arrows), which are located immediately superior to the uterus (U). Gadolinium-enhanced MR imaging showed no enhancement within the lesions. Endometriomas were confirmed at surgery and pathologic analysis.
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Figure 13a. Ovarian torsion in a 31-year-old woman who was 30 weeks pregnant and had RLQ pain and nausea. US showed a mildly enlarged right ovary with normal arterial and venous flow. (a) Axial T2-weighted single-shot fast SE image of the right pelvis shows a mildly enlarged right ovary with areas of increased signal intensity in its stroma (arrow), findings consistent with edema. (b) On an axial fat-saturated T2-weighted single-shot fast SE image obtained at the same level, the high signal intensity within the ovarian stroma (*) caused by edema is seen more clearly. Note the peripherally located follicles, which appear prominent due to the stromal edema. A small amount of fluid is also present surrounding the ovary (arrowheads); this fluid was not appreciated without fat saturation. These MR imaging findings are characteristic of ovarian torsion, and the diagnosis was confirmed at surgery.
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Figure 13b. Ovarian torsion in a 31-year-old woman who was 30 weeks pregnant and had RLQ pain and nausea. US showed a mildly enlarged right ovary with normal arterial and venous flow. (a) Axial T2-weighted single-shot fast SE image of the right pelvis shows a mildly enlarged right ovary with areas of increased signal intensity in its stroma (arrow), findings consistent with edema. (b) On an axial fat-saturated T2-weighted single-shot fast SE image obtained at the same level, the high signal intensity within the ovarian stroma (*) caused by edema is seen more clearly. Note the peripherally located follicles, which appear prominent due to the stromal edema. A small amount of fluid is also present surrounding the ovary (arrowheads); this fluid was not appreciated without fat saturation. These MR imaging findings are characteristic of ovarian torsion, and the diagnosis was confirmed at surgery.
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Figure 14a. Ovarian torsion in a 29-year-old woman who was 9 weeks pregnant. (a) Coronal fat-saturated T2-weighted single-shot fast SE image shows enlargement and increased signal intensity of the right fallopian tube (large arrow) due to edema. The right ovary is enlarged (arrowhead), and its stroma is hyperintense relative to that of the left ovary (small arrow). Note the multiple fibroids (*) in the gravid uterus. (b) Axial fat-saturated T2-weighted single-shot fast SE image shows enlargement and increased signal intensity of the right fallopian tube (arrowheads). A twisted configuration of the right ovarian vascular pedicle (arrow) is appreciated within the edematous tube. * = fibroid. Ovarian torsion was confirmed at surgery.
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Figure 14b. Ovarian torsion in a 29-year-old woman who was 9 weeks pregnant. (a) Coronal fat-saturated T2-weighted single-shot fast SE image shows enlargement and increased signal intensity of the right fallopian tube (large arrow) due to edema. The right ovary is enlarged (arrowhead), and its stroma is hyperintense relative to that of the left ovary (small arrow). Note the multiple fibroids (*) in the gravid uterus. (b) Axial fat-saturated T2-weighted single-shot fast SE image shows enlargement and increased signal intensity of the right fallopian tube (arrowheads). A twisted configuration of the right ovarian vascular pedicle (arrow) is appreciated within the edematous tube. * = fibroid. Ovarian torsion was confirmed at surgery.
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Figure 15. Ovarian torsion in ovarian hyperstimulation syndrome after ovulation induction in a 31-year-old woman who was 11 weeks pregnant and presented with acute RLQ pain. Axial fat-saturated T2-weighted fast SE image of the lower pelvis shows the cervix (white arrowhead) and rectum (R). Both ovaries are visible anteriorly and are enlarged with multiple follicles (black arrowheads). These findings are consistent with ovarian hyperstimulation syndrome, which was known to be present clinically. Note the asymmetrical enlargement of the right ovary, which also demonstrates a subtle increase in signal intensity of the stroma (*). A small amount of fluid is seen between the two ovaries (arrow). Although the right ovary had arterial and venous flow at Doppler US, the MR imaging find-ings were consistent with right ovarian torsion, which was confirmed at laparotomy.
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Figure 16a. Ruptured ovarian dermoid cyst in a 59-year-old woman with pelvic pain. (a) Axial T2-weighted fast SE image shows an enlarged uterus (U) and a right adnexal mass (*). A moderate amount of free intraperitoneal fluid (black arrowheads) is seen as high signal intensity tracking posteriorly from the adnexal mass. There is thickening of the posterior peritoneum (white arrowhead). An exophytic nodule (arrow) is seen arising from the adnexal mass. Note the chemical shift artifact (black and white lines at the anterior and posterior margins of the nodule, respectively) between the nodule and the surrounding free fluid, a finding that suggests the presence of fat. (b, c) Axial in-phase (b) and opposed-phase (c) T1-weighted GRE images obtained at the same level show the intermediate-signal-intensity mass in the right adnexa (* in b). The exophytic nodule is seen as an ovoid area of high signal intensity (arrow). A thin hypointense rim (India ink artifact) is seen around the nodule on the opposed-phase image (arrow in c); this artifact is characteristically seen on opposed-phased images at the interface of bulk fat and water. The presence of bulk fat within an adnexal mass is virtually pathognomonic of an ovarian dermoid cyst. A ruptured ovarian dermoid cyst causing chemical peritonitis was found intraoperatively and at histologic analysis. U in b = uterus.
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Figure 16b. Ruptured ovarian dermoid cyst in a 59-year-old woman with pelvic pain. (a) Axial T2-weighted fast SE image shows an enlarged uterus (U) and a right adnexal mass (*). A moderate amount of free intraperitoneal fluid (black arrowheads) is seen as high signal intensity tracking posteriorly from the adnexal mass. There is thickening of the posterior peritoneum (white arrowhead). An exophytic nodule (arrow) is seen arising from the adnexal mass. Note the chemical shift artifact (black and white lines at the anterior and posterior margins of the nodule, respectively) between the nodule and the surrounding free fluid, a finding that suggests the presence of fat. (b, c) Axial in-phase (b) and opposed-phase (c) T1-weighted GRE images obtained at the same level show the intermediate-signal-intensity mass in the right adnexa (* in b). The exophytic nodule is seen as an ovoid area of high signal intensity (arrow). A thin hypointense rim (India ink artifact) is seen around the nodule on the opposed-phase image (arrow in c); this artifact is characteristically seen on opposed-phased images at the interface of bulk fat and water. The presence of bulk fat within an adnexal mass is virtually pathognomonic of an ovarian dermoid cyst. A ruptured ovarian dermoid cyst causing chemical peritonitis was found intraoperatively and at histologic analysis. U in b = uterus.
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Figure 16c. Ruptured ovarian dermoid cyst in a 59-year-old woman with pelvic pain. (a) Axial T2-weighted fast SE image shows an enlarged uterus (U) and a right adnexal mass (*). A moderate amount of free intraperitoneal fluid (black arrowheads) is seen as high signal intensity tracking posteriorly from the adnexal mass. There is thickening of the posterior peritoneum (white arrowhead). An exophytic nodule (arrow) is seen arising from the adnexal mass. Note the chemical shift artifact (black and white lines at the anterior and posterior margins of the nodule, respectively) between the nodule and the surrounding free fluid, a finding that suggests the presence of fat. (b, c) Axial in-phase (b) and opposed-phase (c) T1-weighted GRE images obtained at the same level show the intermediate-signal-intensity mass in the right adnexa (* in b). The exophytic nodule is seen as an ovoid area of high signal intensity (arrow). A thin hypointense rim (India ink artifact) is seen around the nodule on the opposed-phase image (arrow in c); this artifact is characteristically seen on opposed-phased images at the interface of bulk fat and water. The presence of bulk fat within an adnexal mass is virtually pathognomonic of an ovarian dermoid cyst. A ruptured ovarian dermoid cyst causing chemical peritonitis was found intraoperatively and at histologic analysis. U in b = uterus.
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Figure 17a. Isolated fallopian tube torsion in a 28-year-old woman with severe right-sided pelvic pain. A perirectal cyst was seen at endovaginal US. B = bladder. (a) Sagittal T2-weighted fast SE image shows a normal right ovary (black arrowhead) with a cyst (arrow) seen posteroinferiorly. A small amount of free fluid (white arrowhead) is seen above the ovary. (b) Sagittal T2-weighted fast SE image obtained slightly medial to a shows a cyst (*) in the posterior pelvis and a moderate amount of free fluid (arrow). On sequential images, the posterior pelvic cyst was clearly separate from the ovarian cyst. An area of intermediate to high signal intensity (arrowheads) is seen anterior to the tubal cyst with linear areas of low signal intensity in a swirled pattern. (c) Coronal oblique T2-weighted fast SE image of the midpelvis shows the normal uterus (black arrow) resting above the bladder. The right ovarian cyst (white arrow) is seen. Note the swirled appearance of the adnexal tissue (arrowheads) between the right ovary and uterus. At surgery, the paratubal cyst and right fallopian tube were twisted three times. The paratubal cyst was excised, and the tube was found to be viable after detorsion.
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Figure 17b. Isolated fallopian tube torsion in a 28-year-old woman with severe right-sided pelvic pain. A perirectal cyst was seen at endovaginal US. B = bladder. (a) Sagittal T2-weighted fast SE image shows a normal right ovary (black arrowhead) with a cyst (arrow) seen posteroinferiorly. A small amount of free fluid (white arrowhead) is seen above the ovary. (b) Sagittal T2-weighted fast SE image obtained slightly medial to a shows a cyst (*) in the posterior pelvis and a moderate amount of free fluid (arrow). On sequential images, the posterior pelvic cyst was clearly separate from the ovarian cyst. An area of intermediate to high signal intensity (arrowheads) is seen anterior to the tubal cyst with linear areas of low signal intensity in a swirled pattern. (c) Coronal oblique T2-weighted fast SE image of the midpelvis shows the normal uterus (black arrow) resting above the bladder. The right ovarian cyst (white arrow) is seen. Note the swirled appearance of the adnexal tissue (arrowheads) between the right ovary and uterus. At surgery, the paratubal cyst and right fallopian tube were twisted three times. The paratubal cyst was excised, and the tube was found to be viable after detorsion.
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Figure 17c. Isolated fallopian tube torsion in a 28-year-old woman with severe right-sided pelvic pain. A perirectal cyst was seen at endovaginal US. B = bladder. (a) Sagittal T2-weighted fast SE image shows a normal right ovary (black arrowhead) with a cyst (arrow) seen posteroinferiorly. A small amount of free fluid (white arrowhead) is seen above the ovary. (b) Sagittal T2-weighted fast SE image obtained slightly medial to a shows a cyst (*) in the posterior pelvis and a moderate amount of free fluid (arrow). On sequential images, the posterior pelvic cyst was clearly separate from the ovarian cyst. An area of intermediate to high signal intensity (arrowheads) is seen anterior to the tubal cyst with linear areas of low signal intensity in a swirled pattern. (c) Coronal oblique T2-weighted fast SE image of the midpelvis shows the normal uterus (black arrow) resting above the bladder. The right ovarian cyst (white arrow) is seen. Note the swirled appearance of the adnexal tissue (arrowheads) between the right ovary and uterus. At surgery, the paratubal cyst and right fallopian tube were twisted three times. The paratubal cyst was excised, and the tube was found to be viable after detorsion.
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Figure 18. Acute degeneration of a fibroid in a 28-year-old woman who was 17 weeks pregnant and had progressive RLQ pain. US showed a mass in the RLQ at the point of maximum tenderness. The right ovary was not seen. MR imaging was performed in an attempt to differentiate between ovarian disease and an exophytic fibroid. Axial fat-saturated single-shot fast SE image shows the gravid uterus and placenta (P). An exophytic round mass (arrowheads) with a broad base of attachment to the right side of the uterus is seen and demonstrates diffuse high signal intensity due to edema. A focal area of very high signal intensity (arrow) within the mass is indicative of necrosis. The MR imaging findings are typical of acute degeneration in an exophytic fibroid. The patient’s symptoms improved with conservative treatment.
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Figure 19a. Acute degeneration of fibroids after cesarean section in a 38-year-old woman with acute onset of pelvic pain, fever, and leukocytosis. (a) Axial 3D fat-saturated T1-weighted GRE image of the upper pelvis shows three areas of increased signal intensity (arrows) within the enlarged uterus, findings suggestive of red (hemorrhagic) degeneration of uterine fibroids. (b) Axial subtracted (postcontrast minus precontrast) 3D fat-saturated T1-weighted GRE image obtained at the same level shows lack of enhancement in the three fibroids (*). Acute degeneration of fibroids after cesarean section can cause post-partum pelvic pain and fever, which can mimic a postoperative abscess. The patient’s symptoms improved with conservative treatment.
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Figure 19b. Acute degeneration of fibroids after cesarean section in a 38-year-old woman with acute onset of pelvic pain, fever, and leukocytosis. (a) Axial 3D fat-saturated T1-weighted GRE image of the upper pelvis shows three areas of increased signal intensity (arrows) within the enlarged uterus, findings suggestive of red (hemorrhagic) degeneration of uterine fibroids. (b) Axial subtracted (postcontrast minus precontrast) 3D fat-saturated T1-weighted GRE image obtained at the same level shows lack of enhancement in the three fibroids (*). Acute degeneration of fibroids after cesarean section can cause post-partum pelvic pain and fever, which can mimic a postoperative abscess. The patient’s symptoms improved with conservative treatment.
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Figure 20a. Dilated gonadal vein in a 27-year-old woman who was 29 weeks pregnant and presented with RLQ pain. (a) Axial 2D TOF GRE image of the midabdomen shows a moderately enlarged right gonadal vein (black arrow) and periovarian venous varices (arrowheads). Note the normal appendix (white arrow) with low signal intensity due to air or oral contrast material in its lumen. (b) Sagittal T2-weighted single-shot fast SE image shows moderate right hydronephrosis with dilatation of the renal pelvis (white arrow). Note the extrinsic compression of the proximal ureter (arrowhead) by the enlarged gonadal vein (black arrow). It is unclear if the gonadal vein was the cause of or contributed to the patient’s symptoms, which improved after delivery.
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Figure 20b. Dilated gonadal vein in a 27-year-old woman who was 29 weeks pregnant and presented with RLQ pain. (a) Axial 2D TOF GRE image of the midabdomen shows a moderately enlarged right gonadal vein (black arrow) and periovarian venous varices (arrowheads). Note the normal appendix (white arrow) with low signal intensity due to air or oral contrast material in its lumen. (b) Sagittal T2-weighted single-shot fast SE image shows moderate right hydronephrosis with dilatation of the renal pelvis (white arrow). Note the extrinsic compression of the proximal ureter (arrowhead) by the enlarged gonadal vein (black arrow). It is unclear if the gonadal vein was the cause of or contributed to the patient’s symptoms, which improved after delivery.
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Figure 21a. Distal ureterolithiasis in a 39-year-old woman who was 11 weeks pregnant and had right-sided abdominal pain. US showed right hydronephrosis and a calculus in the distal ureter. MR imaging was performed due to worsening symptoms. (a) Sagittal fat-saturated T2-weighted single-shot fast SE image shows hydronephrosis (arrow) and extensive retroperitoneal fluid (arrowheads) around the right kidney, an appearance suggestive of forniceal rupture. (b) Coronal reformatted image from axial 3D fast imaging with steady-state acquisition shows a filling defect (arrow) in the distal right ureter (arrowheads), a finding consistent with a ureteral calculus. B = bladder. The patient’s symptoms resolved after ureteroscopy with basket extraction of the calculus followed by placement of a double-J stent.
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Figure 21b. Distal ureterolithiasis in a 39-year-old woman who was 11 weeks pregnant and had right-sided abdominal pain. US showed right hydronephrosis and a calculus in the distal ureter. MR imaging was performed due to worsening symptoms. (a) Sagittal fat-saturated T2-weighted single-shot fast SE image shows hydronephrosis (arrow) and extensive retroperitoneal fluid (arrowheads) around the right kidney, an appearance suggestive of forniceal rupture. (b) Coronal reformatted image from axial 3D fast imaging with steady-state acquisition shows a filling defect (arrow) in the distal right ureter (arrowheads), a finding consistent with a ureteral calculus. B = bladder. The patient’s symptoms resolved after ureteroscopy with basket extraction of the calculus followed by placement of a double-J stent.
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Copyright © 2007 by the Radiological Society of North America.
