Lower Abdominal Pain Aashesh Verma July 2013 Dr. Sclamberg
& Dr. Cameron
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Disease Expected Imaging
Treatment Options Our Patient Outline
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Disease Expected Imaging
Treatment Options Our Patient Outline
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The patient is a 45 y/o female with a known history of fibroids
diagnosed on US at OSH who presents to the ED with progressively
worsening lower abdominal pain. The patient describes the pain as
achy and cramping located in the LLQ, RLQ and suprapubic regions.
The patient denies any f/c, n/v, bleeding or diarrhea/constipation.
History
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Vitals: Stable General: NAD, A&Ox3 Abdominal: Soft,
distended, normoactive BS, ttp in LLQ and RLQ, no
hepatosplenomegaly, multiple lower abdominal masses are palpable
Physical
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Disease Expected Imaging
Treatment Options Our Patient Outline
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ACR Appropriateness Criteria:
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Disease Expected Imaging
Treatment Options Our Patient Outline
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Several heterogeneously enhancing lesions are visualized within
the abdomen and pelvis One mass has a lobulated continuation with
the right aspect of the uterus The uterus itself has a
leiomyomatous appearance Left-para aortic space has several
lobulated hypodense masses Mild to moderate ascites CT Abd-Pelvis
w/ Contrast MRN: 6572547 Accession #: 5311403
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Disease Expected Imaging
Treatment Options Our Patient Outline
History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Fibroids Expected Imaging
Treatment Options Our Patient Outline
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Leiomyomas, or fibroids, are benign monoclonal tumors that
typically originate from the smooth muscle of the uterine
myometrium Fibroids are the most common uterine neoplasm, occurring
in up to 70% of women by age 50 More common in African American
women, and typically more severe Hormone dependent, respond to both
Estrogen and Progesterone Risk Factors include early age of
menarche and obesity (likely secondary to increased Estrogen
exposure) Fibroids
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Classification of Fibroids Stewart, 2012
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As fibroids enlarge, they can outgrow their blood supply,
resulting in various types of degeneration Hyaline degeneration
Homogeneous plaques of proteinaceous tissue in extracellular space
Myxoid Degeneration Gelatinous, hyaluronic acid rich
mucopolysaccharides Calcification Cystic Degeneration Red
(hemorrhagic) Degeneration Secondary to hemorrhagic infarction,
during pregnancy Fibroids
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Majority of women are asymptomatic 20 50% have symptoms that
include: Abnormal Uterine Bleeding Most Common Symptom Pelvic Pain
and Pressure Secondary to Mass Effect Reproductive Dysfunction
Secondary to distortion of the uterine cavity Fibroids
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Fibroids Expected Imaging
Treatment Options Our Patient Outline
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Usually not identified on plain X-Ray Seen only if they are
calcified or rarely as a large soft tissue mass displacing bowel
gas Plain Radiography
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KUB Calcification Overlying the Left Hip CT Subsequently shows
Calcified Fibroid Sue and Sarah, 2009
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Ideally the initial investigation to examine the female pelvis
Transvaginal scans are more sensitive, able to detect fibroids as
small as 5mm Findings: Well-defined solid mass with whorled
appearance Usually similar echogenicity to myometrium May cause
alteration of normal uterine contour Often show a degree of
posterior shadowing Ultrasound
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Transvaginal Ultrasound Arrow: 1.1cm Sub- mucosal Fibroid
Arrow- heads: showing posterior shadowing Sue and Sarah, 2009
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Transabdominal Ultrasound Bulky Uterus 10cm submucosal fibroid
between cursors Sue and Sarah, 2009
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Transabdominal US 7cm intramural fibroid Arrows: cystic areas
Sue and Sarah, 2009
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MR is the most accurate imaging technique for detection and
localization of fibroids More sensitive than US Demonstrates
uterine zonal anatomy Good for differentiating between: Submucosal
Intramural Subserosal MRI
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Nondegenerate uterine fibroids have a typical appearance:
Well-circumscribed masses of homogeneously decreased signal
intensity compared to the myometrium on T2- weighted images
Degenerated fibroids have a variable appearance: Hyaline or
Calcific Degeneration Low Signal Intensity on T2, similar to
standard fibroids Cystic Degeneration High Signal Intensity on T2,
the cystic areas do not enhance Myxoid Degeneration Very high
Signal Intensity on T2, enhance minimally with contrast Necrotic
Degeneration Low Signal Intensity on T2 Red (hemorrhagic)
Degeneration Peripheral high signal intensity on T1 Variable
intensity on T2, with/without low-intensity rim MRI
Axial T1-weighted Red Degeneration: Peripheral High Signal
Intensity Murase, et al. 1999
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Axial T1-weighted with Contrast Cystic Degeneration: Arrows:
areas that do not enhance represent cystic degeneration Murase, et
al. 1999
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Sagittal T2-weighted Myxoid Degeneration: Well circumscribed
mass, with components of high signal intensity (arrowheads) Sue and
Sarah, 2009
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Not the primary modality for diagnosing or evaluating fibroids
However, fibroids are often found incidentally on CT Typical
Finding: bulky, irregular uterus or mass in continuity with the
uterus IV contrast is often heterogeneous Degeneration: diminished
contrast enhancement and areas of low attenuation Key Finding:
Solid mass-type calcifications in the uterus are the most specific
sign for leiomyomas CT
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Axial CT with contrast Several bulky, irregular masses in
continuity with the uterus with areas of calcification (arrows) Sue
and Sarah, 2009
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Axial Contrast-Enhancing CT Bennet, et al. 2002 Thick walled
mass with air fluid level with a coarse calcification (arrow)
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Axial CT Sue and Sarah, 2009 Large heterogeneous mass
Histologically confirmed to be a partially degenerate fibroid
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Fibroids Expected Imaging
Treatment Options Our Patient Outline
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Asymptomatic fibroids can be followed without intervention
Gonadotropin-releasing hormone agonists are considered the most
effective medical therapy Surgery is indicated for abnormal uterine
bleeding or bulk-related symptoms Hysterectomy Myomectomy
Endometrial Ablation (if only submucosal fibroids) Treatment
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IR Options: Uterine Artery Embolization Women who wish to
preserve their uterus Advantages: shorter hospital stay, less pain
Disadvantages: higher failure rate with larger fibroids High rate
of re-intervention for treatment failure Magnetic Resonance Guided
focused Ultrasound Premenopausal women who have completed
childbearing Advantages: rapid recovery and low short-term
morbidity Disadvantages: time consuming and costly Treatment
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History and Physical Choice of Imaging Radiographic Findings
Differential Diagnoses Background on Fibroids Expected Imaging
Treatment Options Our Patient Outline
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Patient was discharged from the ED and sent to OB/GYN to obtain
specimen for pathology, with expected diagnosis of diffuse
leiomyomatosis Records do not show a pathological specimen at this
time Follow-up
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Murase, E ; Siegelman, ES ; Outwater, EK ; et al. Uterine
leiomyomas: Histopathologic features, MR imaging findings,
differential diagnosis, and treatment Radiographics. 1999. 19;5:
1179 97. Wilde S, Scott-Barrett S. Radiological appearances of
uterine fibroids. Indian J Radiol Imaging. 2009.
Jul-Sep;19(3):222-31. Bennett GL, Slywotzky CM, Giovanniello G.
Gynecologic causes of acute pelvic pain: spectrum of CT findings.
Radiographics. 2002. Jul- Aug;22(4):785-801. Stewart, Elizabeth A.
"Epidemiology, Clinical Manifestations, Diagnosis, and Natural
History of Uterine Leiomyomas (fibroids)." UpToDate. UpToDate, 1
June 2012. Web Stewart, Elizabeth A. "Overview of Treatment of
Uterine Leiomyomas (fibroids)." UpToDate. N.p., 27 Feb. 2012. Web.
Works Cited and Referenced