Adnexal USG

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My talk on Adnexal USG at Varanasi AICOG 2012

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Adnexal USG

  1. 1. Dr.Sameer Dikshit
  2. 2. • When evaluating the adnexa, attempt should be first made to identify the ovaries• Once identifies, they should be used as reference point• Ovaries should be examined in 2 orthogonal planes• Ovaries may not be identified in cases before and after puberty
  3. 3. • The normal fallopian tubes are not identified• If any pathology is seen, size and sonographic nature of the lesion should be documented• Spectral , color and power doppler examination should be performed• Finally cul-de-sac should be examined posterior to the uterus
  4. 4. • Ovaries • Pelvic vessels• Fallopian Tubes • Vestigial Structures• Broad Ligament
  5. 5. • Bowel• Fluid in pouch of Doughlas
  6. 6. • Pelvic Kidneys• Pelvic Spleen
  7. 7. • Ovaries • Pelvic vessels• Fallopian Tubes • Vestigial Structures• Broad Ligament
  8. 8. • Bowel• Fluid in pouch of Doughlas
  9. 9. • Ring of fire in ectopic pregnancy
  10. 10. • Is a mass present?• Is this the same mass which a clinician feels?• Is the mass, a cause of pain?
  11. 11. • Cystic• Complex• Solid
  12. 12. Completely Cystic Multiple SeptatePhysiological Ovarian Endometrioma CystadenomaCystsCystadenomas Multiple follicular cystsHydrosalpinxEndometriomasParovarian CystHydatid Cyst of Morgagni
  13. 13. Predominantly cystic Predominantly solidCystadenomas CystadenocarcinomaTubo-ovarian abscess Germ Cell TumorEctopic PregnancyCystic Teratomas
  14. 14. Uterine ExtrauterineLeiomyoma Ovarian tumorUterine Sarcoma, Carcinoma
  15. 15. • Peripheral ovarian tissue
  16. 16. • Peripheral ovarian tissue
  17. 17. • No rim of ovarian tissue• Probe pressure to separate ovary and the cyst
  18. 18. • Larger than mature follicle• Between 3-8 cm• Thin walls• No septation• No solid structures
  19. 19. • Usually unilateral• Usually regresses in 2 cycles• If it persists after 3 cycles, then it is not functional
  20. 20. • Central area of low level echoes• Lacy reticular pattern• Occasionally septations
  21. 21. • Reabsorption of blood in corpus hemorrhagicum• Usually less than 4 cm• May accompany Intra Uterine Pregnancy
  22. 22. • No demonstrable central flow• Ring of Fire
  23. 23. • Fusiform anechoic structure• Tapers towards the uterus• No peristalsis
  24. 24. • Complex internal appearance
  25. 25. • Typical endometrioma is a unilocular cyst with homogeneous low level echogenicity
  26. 26. • Ground glass echogenicity
  27. 27. • Mucinous• Hemorrhagic Corpus Cystadenoma Luteum • Granulosa Tumours• Dermoid cyst • Tubo Ovarian Abscess
  28. 28. • Clear fluid
  29. 29. • Thick septations• Low internal echoes
  30. 30. • Complex mass• Predominantly solid mass with echogenic internal echoes
  31. 31. • Papillations
  32. 32. • Diameter >4 cm • Ascites• Thick wall or thick septum >3 cm • Fixed mass• Papillations
  33. 33. • Serous Cystadeno- carcinoma• Inner wall papillations
  34. 34. • Hydrosalpinx
  35. 35. • Rapid vascularization in malignant masses• Tumor vessels lack smooth muscles• Malignant masses have AV connections
  36. 36. • IOTA (International Ovarian Tumor Analysis group) consensus statement• Scoring • No blood flow Score 1 • Minimal blood flow Score 2 • Moderate blood flow Score 3 • Highly vascular Score 4• Score of 3 or more Highly suggestive of malignancy
  37. 37. • RI < 0.6• PI < 1.0
  38. 38. • Movement of particulate matter within fluid due to energy transfer when ultrasound wave is directed to it• Hold the transducer still and then view movement of particles AWAY from the transducer• Can be demonstrated in cysts with fluid containing low level echogenicity
  39. 39. • Presence of acoustic streaming means that the fluid is less viscous• Thus, it is not seen in Endometriomas• Used as a test to distinguish endometriomas
  40. 40. • Standardization of sonographic description of ovarian tumours
  41. 41. Inner Wall PapillationsContents
  42. 42. • Age • Irregular internal cyst• Personal history of walls ovarian cancer • Presence of purely solid• Largest diameter of the tumor lesion • Color score• Largest diameter of • Presence of acoustic largest solid component shadows• Presence of ascites • Current Hormonal• Presence of flow in therapy papillary projections • Pain during examination
  43. 43. • Score > 9  suspicious of malignancy• Additional risk factors • Mean diameter > 10 cm • Bilaterality • Presence of ascites • RI < 0.6 • Serum CA 125 >35 IU/mL
  44. 44. • 1 point each for • Total score= 0 U=0 • Unilocular • Total score=1 U=1 • Solid areas • Total score=>2 U=3 • Bilateral • Ascites • Intra abdominal Mets
  45. 45. • Pre-Menopausal  M=1• Post-Menopausal  M=3
  46. 46. • RMI 1 (Jacobs)= U X M X CA-125
  47. 47. RMI score Risk<25 Low25-250 Moderate>250 High
  48. 48. • Pelvic Congestion Syndrome postulated as cause of chronic pelvic pain• Venography is the gold standard• However, ultrasound can still be used for diagnosis
  49. 49. • Dilated ovarian vein > 5 mm• Tortuous veins around ovary and uterus (> 5mm)• Venous plexus crossing from one side to another• Change of flow direction with Valsalva maneuver• Increase in size of veins with Valsalva maneuver
  50. 50. • Enlargement of the ovary• Abnormal ovarian position anterior to the uterus• Free fluid in the pouch of Doughlas
  51. 51. • Coiling for blood vessels on 2D and colour Doppler

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