MRI of Acute Abdominal Pain in Pregnancy...MRI of Acute Abdominal Pain in Pregnancy Ivan Pedrosa, M.D. Chief of MRI Jack Reynolds MD Chair in Radiology Associate Professor of Radiology

MRI of Acute Abdominal Pain in Pregnancy

I v a n Pe d ro s a , M . D.C h i e f o f M R I

J a c k R ey n o l d s M D C h a i r i n R a d i o l o g yA s s o c i a t e P ro f e s s o r o f R a d i o l o g yU T S o u t h we s t e r n M e d i c a l C e n t e r

A d v a n c e d I m a g i n g R e s e a rc h C e n t e rWednesday, October 3, 2012

NON SURGICALLigamentous Laxity

Hemorrhagic Corpus Luteum

Degenerating Fibroids

GU tract

GI tract

SURGICALAcute Appendicitis

Ectopic Pregnancy

Ovarian TorsionWednesday, October 3, 2012

Location of the Appendix

Baer et al. JAMA 1932

Wednesday, October 3, 2012


Baer et al. JAMA 1932 Pedrosa et al. Radiology 2006Oto et al. AJR 2006

Spearman Rank Correlation:0.44 (P-value: 0.003)





















C



C



C



C



C



C



C



C


Tilting of the Cecum

Lee K. et al. Radiology 2008Wednesday, October 3, 2012


α



α



α



α



α

specificity 98%


MRI Protocol


MRI ProtocolUS prior to MRI



1.5T (No 3T)



1.5T (No 3T)

No Gadolinium



1.5T (No 3T)

No Gadolinium

Supine, Phase Array Body Coil



1.5T (No 3T)

No Gadolinium


Oral prep (1.5 hours)450 mL Gastromark (Mallinckrodt Medical Inc., St. Louis, MO)[iron oxide]

300 mL Readi-cat 2 (EZEM Canada Inc., Westbury, NY)[barium sulfate]

Liebig, T et al. Mag Reson Med 1993



1.5T (No 3T)

No Gadolinium


Oral prep (1.5 hours)450 mL Gastromark (Mallinckrodt Medical Inc., St. Louis, MO)[iron oxide]

300 mL Readi-cat 2 (EZEM Canada Inc., Westbury, NY)[barium sulfate]

Liebig, T et al. Mag Reson Med 1993


MRI Protocol


T2W SSFSE / HASTE (T2-WI)AxialCoronalSagittal

MRI Protocol



Axial T2W Fat-Sat SSFSE / HASTE

MRI Protocol



Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOF

MRI Protocol



Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOFAxial T1W GRE in- and out-of-phase

MRI Protocol



Axial T2W Fat-Sat SSFSE / HASTEAxial 2D T2* TOFAxial T1W GRE in- and out-of-phaseAxial DWI (b=850)

MRI Protocol





Normal Appendix

Collapsed Intraluminal AirWednesday, October 3, 2012

Normal Appendix


Normal Appendix


Is the Appendix Obstructed?

Normal/Abnormal? AppendicitisNormal

T2-W SSFSE Bailey et al. Applied Radiology 2012Wednesday, October 3, 2012

Air-Filled Appendix

T2W SSFSE (spin echo) TOF (GRE)


Air-Filled Appendix



Air-Filled Appendix



Air-Filled Appendix


Blooming Effect = Intraluminal AirWednesday, October 3, 2012

Air-Filled Appendix



Air-Filled Appendix



Appendix vs. Gonadal Varices

SSFSE



SSFSE


TOF


SSFSE


TOF


SSFSE


TOF


SSFSE

Intraluminal Air (Blooming)Collapsed (intermediate signal)


Appendicitis: MR Criteria



NormalDiameter ≤ 6 mmAir in its lumen (blooming effect on T2* TOF)




AbnormalDiameter > 7 mmFluid-filled lumenPeriappendiceal fat strandingRLQ abscess/phlegmon




AbnormalDiameter > 7 mmFluid-filled lumenPeriappendiceal fat strandingRLQ abscess/phlegmon

InconclusiveDiameter between 6-7 mm without ancillary findings


Mild Appendicitis


Mild Appendicitis


Mild Appendicitis


Mild Appendicitis


Appendicitis + Appendicolith










Suppurative Appendicitis








Fat Saturation in Mild Acute Appendicitis

SSFSE SSFSE + FSWednesday, October 3, 2012









Appendiceal Phlegmon

27 wks



27 wks

C



27 wks

C



32 wks27 wks

C



32 wks27 wks

C



32 wks27 wks

C


DWI in Appendicitis

SSFSE DWI (b=1000)Wednesday, October 3, 2012

DWI in Appendicitis


DWI in Appendicitis


DWI in Appendicitis

SSFSE DWI (b=1000) FusedWednesday, October 3, 2012

Inconclusive Result


Inconclusive Result


Inconclusive Result


Initial Experience


Initial Experience

Prospective diagnosis (51 pts): 4 TP, 3FP, 0 FN, 44 TN

Pedrosa I et al. Radiology 2006Wednesday, October 3, 2012

Initial Experience


Sensitivity 100%, NPV 100%


Initial Experience


Sensitivity 100%, NPV 100%

1 CT / 51 patients to confirm tip appendicitis


“Ruling-out” Acute Appendicitis



MR → normal appendix seen:




89% (20/23) Oto et al. Radiology 2005





87% (116/134) Pedrosa et al. Radiology 2009






US → normal appendix typically not seenNegative Result = Ambiguous result






US → normal appendix typically not seenNegative Result = Ambiguous result

Do we need an US?


Surgical Conditions

Ectopic Pregnancy

Ovarian Torsion


Ovarian Torsion

MR Findings

Tubal thickening

Ovarian enlargement

Hyperintense ovarian stroma on T2-W (probably related to edema)

Ghossain MA et al. JMRI 2004

Swirled vascular pedicle


Ovarian Torsion


Ovarian Torsion


Ovarian Torsion


Ovarian Torsion


Hemorrhagic Corpus Luteum

Degenerated Fibroids

GU tract pathology

GI tract pathology

Right ovarian vein varices

Non-Surgical Conditions


Fibroid degeneration

T2-WI T1-WIWednesday, October 3, 2012





T2W SSFSE

DWI in Fibroid degeneration


T2W SSFSE



T2W SSFSE



DWI (b=850)

T2W SSFSE



DWI (b=850)

T2W SSFSE



DWI (b=850)

T2W SSFSE



Hydronephrosis

Pregnancy hydronephrosis

Passed Ureteral StoneRoy C. Magn Reson Imaging 1995


Hydronephrosis




Hydronephrosis




Hydronephrosis




Hydronephrosis




Ureteral StoneWednesday, October 3, 2012



Ureteral Stone Pseudo-stoneWednesday, October 3, 2012




Ureteral Stone

B


Ureteral Stone

B


Ureteral Stone

B


Fat Sat SSFSE

Ureteral Stone

B


Fat Sat SSFSE

Ureteral Stone

B


Fat Sat SSFSE

3D FIESTA

Ureteral Stone

B


Fat Sat SSFSE

3D FIESTA

Ureteral Stone

B


Fat Sat SSFSE

3D FIESTA

Ureteral Stone

B


Pyelonephritis

T2 FSE FS

Dipstick Urinanalysis: -Wednesday, October 3, 2012

Pyelonephritis

T2 FSE FS


Pyelonephritis

T2 FSE FS DWI (b=1000)


Pyelonephritis



Pyelonephritis



Pyelonephritis


Dipstick Urinanalysis: - Final culture: Gram +Wednesday, October 3, 2012

Clinical Outcomes (2002-07)

148 ptsAll

patientsEstimated

(MRI negative) Literature

Negative Laparotomy

Rate30% 7% 20-52%

Perforation Rate

21% 21% 55%

Pedrosa et al. Radiology 2009


Conclusion


Dx of Surgical and Non-surgical dz

Conclusion



Anatomic changes in right colon

Conclusion




MRI Protocol - short but comprehensive

Conclusion




MRI Protocol - short but comprehensive

MRI findings in acute appy, other GI dz, ovarian torsion, degenerating fibroids, ureteral stone vs pregnancy-hydro

Conclusion


[email protected] Wednesday, October 3, 2012

Documents

MRI of Acute Abdominal Pain in Pregnancy...MRI of Acute Abdominal Pain in Pregnancy Ivan Pedrosa, M.D. Chief of MRI Jack Reynolds MD Chair in Radiology Associate Professor of Radiology