The Role of Ultrasound in the Diagnosis of Pelvic Inflammatory Disease.pdf

The Role of Ultrasound in the Diagnosis

and Management of Pelvic Inflammatory

Disease

Word Count: 3,005

Gynaecological Ultrasound: HMSU-7030

Name: Benn Berrigan

Submission Date: 28th

February 2013

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1. Aims & Objectives

The aim of this case study is to evaluate the role of gynaelogical ultrasound in the diagnosis

and management of pelvic inflammatory disease (PID). To facilitate this aim the following

objectives were devised:

1. To describe and examine a case of PID with regard to the use of gynaelogical

ultrasound.

2. To review peer-reviewed literature relating to PID.

3. To evaluate and compare the role of gynaelogical ultrasound with other relevant

diagnostic imaging modalities in the diagnosis and management of PID.

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2. Rationale

Pelvic Inflammatory Disease (PID) is a common condition, characterised as the spread of

bacterial infection from the vagina to the upper genital tract (Ross, 2010; Massouh, 2007),

see figure 1. Encompassing all upper genital infections, PID affects 1 in 50 women of

reproductive age in the United Kingdom per year (NHS Choices, 2012) and is diagnosed in

around 2% of general practitioner (GP) consultations of women aged 16-45 (Healey &

Quinn, 2010). Young women are predominately at the highest risk of disease, whilst the age

range of this group varies within literature between 15-24 (Hodson, 2009) to 16-19 (Barrett &

Taylor, 2005); for simplification, it is deemed of use to categorise this group as being 25

years or below (Raymond, 2002).

PID may acutely present with a range of clinical symptoms (see table 1) and is often the

result of ascending bacterial infection from the endocervix, which literature has historically

implicated the Neisseria gonorrhoea or Chlamydia trachomatis organisms as common causes

(Raymond, 2002). However the UK national guidelines for the management of PID (Ross &

McCarthy, 2011) found that these sexually transmitted organisms only account for one

quarter of PID cases, with resident vaginal flora also implicated. Less commonly infection

Figure 1: Pelvic female anatomy (Macdonald & Magill-Cuerden, 2010).

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may also develop by direct spread from existing abdominal infections, such as diverticulitis

or appendicitis (Hodson, 2009).

Clinical Symptoms of PID Primary Risk Factors for PID

Lower abdominal pain (typically bilateral) Age 25 years (Raymond, 2002)

Fever (greater than 38C) Exposure to STD (sexually transmitted

disease)

Adnexal tenderness History of previous PID

Cervical motion tenderness Use of IUCD (intrauterine contraceptive

device) within first few weeks

Abnormal vaginal discharge Multiple sexual partners

Raised inflammatory blood markers and /

or raised white cell count Vaginal douching

Table 1: Clinical symptoms (left) suggestive of PID (Ross & McCarthy, 2011) and primary

risk factors (right) associated with development of PID (Healey & Quinn, 2010).

At initial presentation PID will often be diagnosed through clinical assessment alone (Healey

& Quinn, 2010), with empiric treatment to be commenced in at-risk women, especially with

those at risk of STDs and where pelvic or lower abdominal pain is present (Centers for

Disease Control and Prevention (CDCP), 2010). Laboratory testing may be used to confirm

the presence of sexually transmitted bacterial agents that are deemed responsible for causing

PID, raising the positive predictive value (PPV) of the clinical diagnosis (CDCP, 2010).

However Gaitn et al. (2002) found the laboratory testing of endometrial cultures often to be

imprecise, with a sensitivity of 83% but a specificity of only 26%; clinical diagnosis alone

was found to be 87% and 50% respectively on admission. Significantly, literature also finds

that clinical diagnosis may be equivocal, with a positive predictive value of only 65%

(Jaiyeoba & Soper, 2011). PID diagnosis therefore may be challenging to predict, however

misdiagnosis can result in serious long term sequelae such as recurrent infection, chronic

pain, ectopic pregnancy and infertility (Ross, 2010).

Increasingly diagnostic imaging is being utilised to differentiate PID from differential

diagnoses, especially for patients with equivocal clinical findings, chronic disease or when

the patient has developed complications (Healey & Quinn, 2010). Historically the gold

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standard diagnostic examination for PID has been laparoscopy (Jaiyeoba & Soper, 2011), a

surgical procedure that directly visualises abdominal and pelvic structures through an

abdominal incision. Pelvic ultrasound uses high-frequency sound waves to visualise the

internal structures within the body and is now considered to be the first-line imaging

investigation for PID (Healey & Quinn, 2010); it may also be of benefit in patients with

equivocal clinical findings or when there is suspicion of further clinical complications

(Thomassin-Naggara et al., 2012). This case study will examine a referral for possible PID to

a gynaelogical ultrasound service, discuss the clinical findings and evaluate the role of

ultrasound in the care pathway of the patient.

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3. Case Study

A 39 year-old female presented to the hospital via the GP emergency admissions unit with

menorrhagia, nausea, fever and generalised abdominal tenderness with severe bilateral iliac

fossa pain.

Clinical history:

Negative pregnancy test

Raised c-reactive protein (CRP) level of 146 mg/L

Leucocytes positive urine dip

Intrauterine contraceptive device (IUCD) in situ

Before this admission, the patient had no previous diagnostic imaging examinations

undertaken. Chest and abdominal x-ray images (appendix 1) had been obtained that morning

to rule out bowel perforation or obstruction, which demonstrated no abnormal pathology.

Upon commencement of empirical antibiotic treatment, the patients symptoms failed to

abate and a gynaecological ultrasound examination was requested to assess for

gynaecological pathology. Due to the given clinical information and symptoms, the request

was vetted to assess for gynaelogical pathology.

The patients pelvis was examined using a Siemens ACUSON S1000. A transabdominal

(TA) examination was first performed utilising a 4MHz curvilinear transducer. A

transvaginal (TV) examination was then performed using a 9MHz curved-array transvaginal

transducer. The bladder, uterus, both ovaries and both adnexae were visualised. The imaging

report can be found in appendix 2.

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4. Results and Images

Figure 2a: TA LS bladder view, note the well distended bladder that could not

be fully visualised in the LS scan field.

Figure 2b: Line diagram of figure 2a.

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Figure 3a: TA LS bladder, second view.


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Figure 4a: TA TS bladder, one of two views taken due to the distended bladder.

Note the large left-sided adnexal mass.


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Figure 5a: TA LS uterus. Note the IUCD present in the uterine cavity.


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Figure 6a: TA TS uterus.


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Figure 7a: TA endometrium, note that IUCD prevents the endometrium from

being assessed.


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Figure 8a: TA left adnexal mass, measuring 5.7 x 4.2 x 4cm, which may have

been the ovary. Note cystic areas within the mass.


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Figure 9a: TA right ovary. This is of a more normal size.


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Figure 10a: TV LS uterus. The IUCD prevents the endometrium from being

properly assessed.


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Figure 11a: TV TS uterus. Note the position of the IUCD, which is

demonstrated well here.


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Figure 12a: TV left adnexal mass, likely to be the left ovary.


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Figure 13a: The use of power Doppler imaging increases the likelihood that this

was the ovary; note the internal iliac artery, which lays close to the position of

the ovary.


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Figure 14a: TV TS of the right ovary. Note the complex mass to the left of this.


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Figure 15a: Sweeping to the left slightly demonstrates a tubular structure this

may represent the diseased right fallopian tube.


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Figure 16a: TV TS of left adnexal mass using power Doppler, note the

increased peripheral vascularity around the fluid filled tubular structure.


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Figure 17a: TV LS of the structure in 16a, note the internal iliac vessel coming

into view in partial long section.


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Figure 18a: TV of the left adnexa. Note that a tubular structure appears around

the mass, this may represent the left fallopian tube.


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5. Discussion

Presentation and Symptoms

The patient presented with a history of severe bilateral iliac fossa pain, menorrhagia, fever

and abdominal tenderness. Literature identifies these symptoms as being typical of PID (Ross

& McCarthy, 2011), which can cause pain due to ensuing inflammatory processes affecting

the endometrium, fallopian tubes and / or ovaries. However there may be a wide variation in

symptoms, as detailed within table 1 p.3, which can vary in effect from subtle, mild to severe

(Jaiyeoba & Soper, 2011); PID may often be challenging to diagnose confidently. Gaitn et

al. (2002) found laboratory testing for causative bacterial agents to have a specificity of only

26% (Gaitn et al., 2002) whilst clinical diagnosis alone may often be equivocal with a

positive predictive value of only 65% (Jaiyeoba & Soper, 2011).

Indeed no single available test provides definitive evidence of PID (Gaitn et al., 2002).

Thomassin-Naggara et al. (2012) highlight that a delay in the commencement of suitable

treatment, of even 24-48 hours, can result in serious long term sequelae such as recurrent

infection, chronic pain, future ectopic pregnancy and infertility. Therefore in-keeping with

UK national guidelines for the management of PID (Ross & McCarthy, 2011), the patient

commenced empirical antibiotic treatment, as her clinical history complied with the basic

criteria which are:

A sexually active female of child bearing age

Recent onset of bilateral lower abdominal pain

Associated adnexal tenderness

Negative pregnancy status

Medeiros et al. (2012) discussed that CRP levels are commonly elevated during most

invasive infections, indeed the patients CRP of 146 mg/L was well in excess of the normal

upper limit of 14 mg/L (Jangjoo et al., 2011). Allied with a high temperature and positive

urine dip for leucocytes, the clinical picture was highly suggestive of abdominal or pelvic

infection (Healey & Quinn, 2010). However Hodson (2009) reasons that such tests cannot

assess the severity of disease and that a high index of suspicion and consideration for the

differential diagnoses of PID (table 2) should be maintained. The most common of which is

ectopic pregnancy (EP), where a developing foetus implants in an area other than the uterine

cavity (McQueen, 2011). There may be around 10,000 cases of EP annually in the UK (Kirk

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& Bourne, 2011); the symptoms include abdominal pain with associated tenderness which

may be localised to a specific area, nausea, amenorrhea and vaginal bleeding (Farquhar,

2005). Around 90% of ectopic pregnancies are tubal (Kirk & Bourne, 2011), where the

fertilised egg is impeded within the fallopian tube, around a third of those cases are caused by

tubal infection or previous surgery. A further risk factor is the use of IUCDs (Farquhar,

2005), which this patient had present in her uterine cavity.

However an EP was clinically unlikely in this case due to the negative pregnancy test, the

bilateral nature of the lower abdominal pain and reported menorrhagia. Further, the patient

reported that she had not missed her last menstrual period. Bates (2006) cautions that a

negative pregnancy test cannot exclude EP, indeed the pregnancy test was of the urine dip

variety, which are variable in sensitivity to levels of human chorionic gonadotrophin (hCG)

(Cole, 2011), a hormone produced by the developing placenta during pregnancy (Bates,

2006). For this reason, the reporter asked the medical team to confirm the negative pregnancy

status, preferably by blood serum test, for greater sensitivity and the ability to quantify hCG

levels.

Regarding the patients menorrhagia, this may have been caused by endometritis,

characterised as infection of the endometrium, which would result in thickening of the

endometrium and associated heavy bleeding during menstruation (Bates, 2006). Other

Differential diagnoses

Ectopic pregnancy

Appendicitis

Urinary tract infection (UTI)

Endometriosis

Ovarian cyst torsion / rupture

Pelvic adhesions (especially if history of previous surgery)

Irritable bowel syndrome

Functional pain of unknown aetiology or origin

Table 2: Differential diagnoses for PID (Hodson, 2009).

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possible causes of menorrhagia include fibroids or endometrial polyps; fibroids, if present,

can distort the endometrium and increase the surface area from which bleeding can occur

(Bates, 2006). Polyps, which are proliferative masses of the endometrial lining, often present

with heavy bleeding (Gould, 2007). Appendicitis was also ruled out due to the bilateral

adnexal tenderness, absence of vomiting and nausea and that the pain had failed to migrate,

factors which Morishita et al. (2007) utilise to rule out appendicitis from PID with 99%

sensitivity.

The Role of Diagnostic Imaging in PID

Thus far the patient had not required radiological input for her diagnosis and initial treatment

for PID, a common occurrence in the literature, where imaging investigations generally offer

low sensitivity for the detection of subtle or mild disease (Healey & Quinn, 2010; Jaiyeoba &

Soper, 2011). Indeed, PID will often be diagnosed through clinical assessment alone (Healey

& Quinn, 2010), with empiric treatment commenced in at-risk women who fulfil the

necessary criteria (Ross & McCarthy, 2011). However the patients worsening symptoms

necessitated an imaging investigation to exclude differential diagnoses and to visualise the

possible progression of disease (Thomassin-Naggara et al., 2012). Healey & Quinn (2010)

found that diagnostic imaging is being increasingly used in this manner, especially for cases

where patients symptoms progress despite treatment, such as with the patient in this case

study.

Historically the gold standard diagnostic examination for PID has been laparoscopy (Jaiyeoba

& Soper, 2011), however Gaitn et al. (2002) identified that its sensitivity may be as low as

65%, especially when disease progression is mild, due to the limitations of visualising only

the superficial aspects of anatomical structures. Furthermore, laparoscopy is time intensive,

requiring a staffed surgical theatre to safely perform the procedure, is surgically invasive and

carries inherent risks due to the necessity for general anaesthesia (Healey & Quinn, 2010;

Ross, 2010). However Jaiyeoba & Soper (2011) conclude that laparoscopy allied with

endometrial biopsy is a comprehensive approach, however it is neither cost-effective nor

practical.

In comparison ultrasound is widely accepted as the imaging modality of choice (Jaiyeoba &

Soper, 2011). It allows for the demonstration of deep soft tissue structures, is relatively

inexpensive and readily available at the patients bedside if needed (Ihnatsenka & Boezaart,

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2010). Gynaecological ultrasound can be performed by two complimentary methods; with

transvaginal (TV) ultrasound a curved array 4-8MHz transducer is partially introduced within

the vaginal vault, providing excellent detail of the endometrium, myometrium and ovaries

(Hughes, 2011, pp. 646), especially when assessing subtle pathology (Healey & Quinn,

2010). Transabdominal ultrasound uses a lower frequency curvilinear transducer, which

permits a panoramic examination of the pelvis and adnexae (Hughes, 2011, pp. 645); the

wide field-of-view can accommodate large pelvic masses (Bates, 2006). With Doppler

ultrasound, increased blood flow related to tissue inflammation and other pathological

conditions may be visualised and assessed, indeed it is considered a reliable indicator of

disease (zbay & Deveci, 2011). The use of TV ultrasound in this case enabled the operator

to correlate the site of the patients reported adnexal tenderness, using slight pressure from

the TV transducer head, in real-time directly against the acquired images on-screen.

However ultrasound is widely deemed to be an operator dependent modality (Bates, 2006).

With inexperienced hands Gaitn et al. (2002) found that ultrasound sensitivity for detection

of PID may be only 32%, rising however to 85% with an experienced operator acquiring

optimal images. This highlights the importance of good quality training for ultrasonographers

and the high diagnostic yield that an experienced sonographer may achieve.

Patient preparation for gynaelogical ultrasound is fairly well tolerated by most women

(Hughes, 2011, pp. 645), which for a TA scan involves having a full bladder. Whilst for a TV

scan the preparation is more psychological, the patient must be given a thorough explanation

of the procedure and provide verbal consent, good communication is essential in maintaining

a positive rapport with the patient (Bates, 2006). The patients privacy and sense of dignity

must be maintained at all times.

An alternate imaging modality for PID is magnetic resonance imaging (MRI), which has been

identified as more accurate than TV ultrasound (Tukeva et al., 1999). Although the value of

the study must be questioned due to age and the recent advancement of ultrasound

technologies. However, MRI can easily demonstrate pathological fallopian tubes, with

varying signal intensity allowing the differentiation of the tubes contents (Kim et al., 2009).

MRI easily differentiates between uterine tissue types, with the endometrium seen as a high

signal stripe in contrast to the inner and outer myometrium (low and medium signals

respectively) (Andrews, 2001). Ovarian masses seen with ultrasound may be characterised by

MRI (Healey & Quinn, 2010), the use of gadolinium contrast agent allows benign and

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malignant masses to be further differentiated (Talbot, 2005). Furthermore MRI is not

invasive, does not use ionising radiation and is truly multi-planar in nature. However it is

expensive, time-consuming and contraindicated for early pregnancy, patients with large body

habitus and those with claustrophobia (Talbot, 2005).

Computed tomography (CT) may present subtle or nonspecific findings in early or mild PID

(Jaiyeoba & Soper, 2011), and therefore may be of limited use in these cases; CT also carries

a high dose burden of ionising radiation which is undesirable in female patients of child

bearing age. However when working through differential diagnoses CT use may be justified

when considering peritonitis, appendicitis, small bowel obstruction or intra-abdominal

abscess (Healey & Quinn, 2010). Furthermore, Jung et al. (2011) found that whilst CT has

low sensitivity towards PID, it can identify tubal thickening which is highly specific for

diagnosing PID.

Ultrasound Appearances

The patients clinical symptoms correlated well with the ultrasound findings. The TA

examination revealed bilateral adnexal pathology that likely represented chronic

inflammatory change. The left adnexa contained a large mass (5.7 x 4.2 x 4cm) which

contained small cystic areas, some of which contained internal echogenicity. This likely

represented an enlarged ovary containing a combination of simple and possibly haemorrhagic

cysts. There was no evidence of free fluid in the pelvis, which if present could indicate cyst

rupture (DeFriend, 2011, pp. 682), ectopic pregnancy (Kirk & Bourne, 2011), malignancy

(Bates, 2006) or PID (Massouh, 2007, pp. 106). Fluid may also be found within the

endometrial space, being indicative of endometritis, which would appear as a linear

hypoechoic area within the uterus (Bates, 2007). However, whilst the IUCD may have

impeded the demonstration of the endometrium itself, no fluid could be seen within the

cavity.

The right ovary, whilst slightly enlarged (4 x 2.2 x 3.4cm) was still around normal limits

(Bates, 2006) and lay immediately adjacent to a larger multi-cystic area that appeared to

contain prominent tubular structures. This area likely represented the right fallopian tube,

which due to the inflammatory processes, appeared distended and thickened, see figure 20;

the walls of which may be noticeably thickened, literature suggests a thickness of around

5mm may be indicative of disease (Timor-Tritsch et al., 1998, cited by Bates, 2006). This

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may be classified as hydrosalpinx (containing fluid), pyosalpinx (containing pus) or a tubo-

ovarian complex abscess (which involves both the tube and the ovary) (Lee & Swaminathan,

2011). Appearances can vary, which highlights the importance of the examination being

conducted by an experienced operator (Bates, 2006).

Figure 19: Normal anatomy of a fallopian tube and ovary (left) and appearance of

hydro/pyosalpinx, associated with early stage salpingo-oophoritis (right) (Kim et al, 2009).

Molander et al. (2001) found that salpingitis (infection of the fallopian tubes) may present

with a solid vascularised homogenous-mass close to the ovary. There was a multi-cystic mass

within the right adnexa, which may have represented salpingo-oophoritis, where the ovaries

and tubes adhere together, creating an early inflammatory mass (Kim et al., 2009). This

would have benefited from further differentiation with MRI (Healey & Quinn, 2010).

Treatment and Management

The patient was referred to a specialist Gynae service and discharged from the hospital with a

suitable empirical treatment regime. However the patient failed to attend the Gynae clinic and

subsequent clinical history could not be obtained. However Ross (2010) states that following

antimicrobial therapy, whilst the signs and symptoms of PID often reside, longer term

sequelae are still a risk; the most common of which is chronic pain (Royal College of

Obstetricians and Gynaecologists, 2008). Ultrasound may be utilised in the future to

investigate differential causes for the pain, due to its stature as a first line investigation tool.

Ultrasound-guided hystero-salpingography (HyCosy) may also be used in possible future

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infertility, due its ability to visualise the fallopian tubes whilst presenting no radiation burden

(Bates, 2006). In cases which fail to respond to treatment, FitzHughCurtis syndrome may

present as right upper quadrant pain, the result of focal peri-hepatitis (Centres for Disease

Control and Prevention, 2011). Ultrasound findings may be nonspecific however (Healey &

Quinn, 2010) and MRI may be more sensitive to subtle inflammatory hepatic changes.

6. Conclusion

Whilst imaging investigations were not initially required for this patients diagnosis and

treatment, a gynaecological ultrasound examination subsequently aided the medical team to

exclude appendicitis and ectopic pregnancy as differential diagnoses; identifying bilateral

adnexal masses that likely represented hydrosalpinx or pyosalpinx (Massouh H, 2007). These

pathologies suggest that the patients PID was in a chronic stage (Healey & Quinn, 2010).

This case study identified that ultrasound has a valuable role as a first line investigation tool

for abdominal or pelvic pain (Ross & McCarthy, 2011). Indeed, no other imaging modality is

as flexible, cost effective and readily available (Bates, 2006). TV ultrasound also provides

excellent higher resolution detail over TA techniques, allied with Doppler ultrasound, this

gives clinicians an ability to identify areas of inflammatory response and increased

vascularity, which may not be visible with the gold standard laparoscopic approach (Gaitn et

al., 2002).

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7. References

Andrews A. (2001). Uterine pathology in Dewbury K, Meire H, Cosgrove D, Farrant P

.(ed). Ultrasound obstetrics and gynaecology. (2nd

edition). Churchill Livingston: London.

pp. 19-34.

Barrett S, Taylor C. (2005). A review on pelvic inflammatory disease. International Journal

of STD & AIDS; 16: 715-721.

Bates J. (ed.) (2006). Practical gynaelogical ultrasound. (2nd

edition). Cambridge University

Press: London.

Centres for Disease Control and Prevention. (2010). Sexually Transmitted Diseases

Treatment Guidelines. MMWR; 59(12): 63-67. Available online:

http://www.cdc.gov/std/treatment/2010/ [Accessed 12th

January 2013].

Cole LA. (2011). The hCG assay or pregnancy test. Clinical Chemistry and Laboratory

Medicine; 50 (4): 617630.

DeFriend D. (2011) Gynaecology: ovaries in Allan PL, Baxter GM, Weston MJ. (ed.)

Clinical Ultrasound. (3rd

edition). London: Churchill Livingston. pp 682.

Farquhar CM. (2005). Ectopic pregnancy. Lancet; 366: 583-591.

Gaitn H, Angel E, Diaz R, Parada A, Sanchez L, Vargas C. (2002). Accuracy of five

different diagnostic techniques in mild-to-moderate pelvic inflammatory disease. Infectious

Diseases in Obstetrics and Gynaecology; 10(4): 171-180.

Gould D. (2007). Menorrhagia: causes, diagnosis and treatment options. Nursing Standard;

21 (24): 44-52.

Healey PR, Quinn D. (2010).Imaging pelvic inflammatory disease. Ultrasound; 18; 119-124.

Hodson, A. (2009). Pelvic inflammatory disease. InnovAiT; 2 (9): 517-521.

Hughes T. (2011). Pelvic anatomy and scanning techniques in Allan PL, Baxter GM,

Weston MJ. (ed.) Clinical Ultrasound. (3rd

edition). London: Churchill Livingston. pp 646.

Ihnatsenka B, Boezaart AP. (2010). Ultrasound: basic understanding and learning the

language. International Journal of Shoulder Surgery; 4 (3): 55-62.

31

Jaiyeoba O, Soper DE. (2011). A practical approach to the diagnosis of pelvic inflammatory

disease. Infectious Diseases in Obstetrics and Gynecology; 2011: 1-6. Available online:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148590/pdf/IDOG2011-753037.pdf

[Accessed 20th January 2013].

Jangjoo A, Varasteh AR, Bahar MM, Meibodi NT, Aliakbarian M, Hoeininejad M, Esmaili

H, Amouzeshi A. (2011). Is C-reactive protein helpful for early diagnosis of acute

appendicitis? Acta Chirurgica Belgica; 111 (4): 219-222.

Jung SI, Kim YJ, Park HS, Jeon HJ, Jeong KA. (2011). Acute pelvic inflammatory disease:

diagnostic performance of CT. The Journal of Obstetrics and Gynaecology Research; 37 (3):

228-235.

Kim MY, Rha SE, Oh SN, Jung SE, Lee YJ, KimYS, Byun JY, Lee A, Kim MR. (2009). MR

imaging findings of hydrosalpinx: a comprehensive review. Radiographics; 29: 495-507.

Kirk E, Bourne T. (2011). Ectopic pregnancy. Obstetrics, Gynaecology and Reproductive

Medicine; 21 (7): 207-211.,

Lee DC, Swaminathan AK. (2011). Sensitivity of ultrasound for the diagnosis of tubo-

ovarian abscess: a case report and literature review. The Journal of Emergency Medicine; 40

(2): 170175.

Macdonald S, Magill-Cuerden J. (2010). Mayes' Midwifery: A Textbook for Midwives. (14th

Ed.) Edinburgh: Elsevier. pp 290, illus.

McQueen A. (2011). Ectopic pregnancy: risk factors, diagnostic procedures and treatment.

Nursing Standard; 25 (37): 49-56.

Massouh H. (2007). Ultrasound in the acute pelvis in Bates J. (ed.) Practical Gynaelogical

Ultrasound. London: Cambridge University Press. pp. 106.

Medeiros IL, Terra RM, Choi EM, Pego-Fernandes PM, Jatene FB. (2012). Evaluation of

serial C-reactive protein measurements after surgical treatment of pleural empyema. Clinics;

67 (3): 243-247. Available online: http://www.scielo.br/pdf/clin/v67n3/a07v67n3.pdf

[Accessed 8th February 2013].

32

Molander P, Sjberg J, Paavonen J, Cacciatore B. (2001). Transvaginal power Doppler

findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound in

Obstetrics & Gynecology; 17 (3): 233-238.

Morishita K, Gushimiyagi M, Hashiguchi M, Stein GH, Tokuda Y. (2007). Clinical

prediction rule to distinguish pelvic inflammatory disease from acute appendicitis in women

of childbearing age. American Journal of Emergency Medicine; 25: 152-157.

NHS Choices. (2012). Pelvic inflammatory disease. National Health Service. Online:

http://www.nhs.uk/conditions/pelvic-inflammatory-disease/Pages/Introduction.aspx

[Accessed 2nd January 2013].

zbay K, Deveci S. (2011). Relationships between transvaginal colour Doppler findings,

infectious parameters and visual analogue scale scores in patients with mild acute pelvic

inflammatory disease. European Journal of Obstetrics & Gynaecology and Reproductive

Biology; 156 (2011): 105108.

Raymond RH. (2002). Pelvic Inflammatory Disease: A clinical challenge. Topics in

Emergency Medicine; 24(4):40-46.

Ross, J. (2010). Pelvic inflammatory disease. Medicine; 38 (5): 255-259. Available online:

http://www.medicinejournal.co.uk/article/S1357-3039(10)00025-3/ [Accessed 19th

December

2012].

Ross J, McCarthy G. (2011). UK national guideline for the management of pelvic

inflammatory disease. London: Clinical Effectiveness Group - British Association for Sexual

Health and HIV. Available online: http://www.bashh.org/guidelines [Accessed 7th January

2013.

Royal College of Obstetricians and Gynaecologists. (2008). Management of acute pelvic

inflammatory disease. (2nd

ed.). London: Royal College of Obstetricians and Gynaecologists.

Available online: http://www.rcog.org.uk/files/rcog-corp/uploaded-

files/T32PelvicInflamatoryDisease2008MinorRevision.pdf [Accessed 7th January 2013].#

Talbot J. (2005) Magnetic Resonance Imaging in Carver E, Carver B. Medical imaging:

techniques, reflection & evaluation. Edinburgh: Churchill Livingston.

33

Thommassin-Naggara I, Darai E, Bazot M. (2012). Gynecological pelvic infection: What is

the role of imaging? Diagnostic and Interventional Imaging; 93: 491-499.

Timor-Tritsch IE, Lerner JP, Monteagudo A, Murphy KE, Heller DS. (1998). Transvaginal

sonographic markers of tubal inflammatory disease. Ultrasound in Obstetrics and

Gynecology; 12: 56-66 cited in Bates J. (2006). Practical Gynaelogical Ultrasound. (2nd

edition). London: Cambridge University Press.

Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. (1999). MR

imaging in pelvic inflammatory disease: comparison with laparoscopy and US. Radiology;

210: 209-216.

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Appendix 1: Previous Diagnostic Imaging

Figure 21: Abdominal x-ray, note the IUCD in the pelvic

rim

Figure 22: Upper abdominal x-ray.

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Figure 23: Chest x-ray.

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Appendix 2: Imaging Report

Normal bladder outline.

Normal uterus with IUCD in good position in the endometrial cavity.

Both adnexal regions are abnormal. On the left there is a 5.7 x 4.2 x 4cm mass-like area

which is probably the left ovary containing small cystic areas, within which there are internal

echoes ? blood ? infection.

Right ovary of more normal size, with a prominent tubular structure and a large complex

multi-cystic area extending into the pouch of Douglas.

With the given clinical history, the concern is of an inflammatory condition; possibly with

pyosalpinx bilaterally. There was no free fluid noted in the pelvis.

The bilateral nature would be against appendicitis. Please reconfirm no missed period.

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The Role of Ultrasound in the Diagnosis of Pelvic Inflammatory Disease.pdf