PID masquerade

PID masquerade

History

This young woman presented with pelvic pain of 24 hours duration. On examination she had pelvic excitation and PID was considered the most likely diagnosis clinically.

Below are the still images transbdominally and transvaginally. Look at the answer which includes a clip and full description of the ultrasound findings.

Pelvic Appendicitis

Transabdominal view of uterus in longitudinal section.

Pelvic Appendicitis

TA view, uterus transverse with ovaries on either side.

Pelvic Appendicitis

Left iliac fossa, bowel gas.

Pelvic Appendicitis

Right iliac fossa, faeces.

Pelvic Appendicitis

Transvaginal view, uterine fundus longitudinal

Pelvic Appendicitis

TV view, cervix longitudinal

Pelvic Appendicitis

TV view, uterus transverse

Pelvic Appendicitis

TV, left ovary

Pelvic Appendicitis

Right ovary with adnexal mass

Pelvic Appendicitis

Right adnexal mass transverse

Pelvic Appendicitis

Right adnexal mass with flow

Pelvic Appendicitis

Right adnexal mass longitudinal

Pelvic Appendicitis

Right adnexal mass with flow

Answer

  • In this case the inflamed appendix lies in the right adnexa between the right ovary and uterus. It is not surprising there was cervical excitation.
  • BHCG was negative for those of you concerned this adnexal mass was an ectopic.

  • Appendicitis is sometimes found on transvaginal ultrasound when transbdominal scanning has been unsuccessful.
  • This case demonstrates the classic features of acute appendicitis listed below, but also shows incongruity of the appendiceal wall and a small walled off periappendiceal abscess.
  • In acute appendicitis the appendix typically develops the following characteristics:
    • Distended to more than 6mm in diameter
    • Non compressible
    • Tender to probe palpation
    • Echogenic mesentry surrounding it
    • Small amount of free fluid
    • Hyperaemia
    • An appendicolith may be present
    • Complications such as perforation and abscess formation may be present

About James Rippey

Emergency physician with a passion for ultrasound and educating the masses @theSonoCave + James Rippey

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