Presentation
A virgin patient with recurrent attacks of heaviness in the pelvis with sometimes acute abdominal pain mainly at the left iliac fossa, menstrual irregularity is also present, no previous operations.
Patient Data
Sausage-shaped left adnexal unilocular cystic lesion with fluid content being isointense in T1 and hyperintense in T2 and T2 fat sat denoting fluid signal with slightly proteinaceous contents, this is confirmed by the presence of faint fluid-fluid level, this cystic lesion is dilated Fallopian tube from the isthmic portion to its distal fimbrial end and seen insinuated in the Douglas pouch, this is important to differentiate it from the elongated para ovarian cyst which is seen in the broad ligament. you need to exclude endometriosis; this will be done by the absent shading sign in T2 which means that if there is hyper intense signal of blood in T1 it cannot being bright in T2 like fluid but it will be isointense or shows mixed signal due to different blood aging.
The right ovary show small cyst with the same fluid signal inside.
No uterine abnormality.
No associated urinary anomalies.
Case Discussion
Tubal dilatation can occur in different pathological situations e.g tubal endometriosis, pelvic adhesion, pyosalpinx, ectopic pregnancy, transient during menstruation in case of narrow cervical os, as obstructive sequelae of tubal or uterine cornual masses and in imperforate hymen and other causes of impaired menstrual drainage.
The nature of accumulated fluid will help to differentiate, it is fluidy in simple occlusion due to adhesion, pus in pyosalpinx and PID, blood in malignancy ectopic pregnancy, imperforate hymen, tubal torsion and endometriosis and finally caseous in TB.
The different fluid will give different signal in MRI help to differentiate them; so that MRI has the upper hand over CT in diagnosis of the fluid nature and better natural tissue contrast resolution.
It is a must to differentiate endometriosis from other causes to avoid many troubles in treatment.
HSG give characteristic appearance of the dilated tube.
US will help to retrieve the nature of aspirated fluid using oblique course of the needle to avoid spillage of the fluid in the peritoneal cavity , if you suspect endometriosis it is better to avoid aspiration.
You must scan the urological system as renal malformations or agenesis may indicate Mullerian duct anomalies.
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