孕妇腹痛影像学表现

1 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Abdominal Pain in a Pregnant Patient Megan Browning, Harvard Medical School Year III Gillian Lieberman, MD January 2007 2 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD (23+6 weeks gestation) HPI ƒ Woke with 5/10 crampy abdominal pain followed by nausea, vomiting, ƒ Pain intensified over 12 hours ƒ Presented to the ED at St. Luke’s Hospital ƒ Diagnostic tests and an imaging study were inconclusive. ƒ Monitored over next 12 hours ƒ Transferred to BIDMC 24 hours after the onset of pain ROS ƒ Occasional flatus ƒ No hx of pain after eating, flank pain, dys/hematuria, hematochezia, melana, vaginal discharge, new sexual partners, PID, no ingestion of exotic foods/undercooked meats Ms.O is a 21yo pregnant female 3 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Physical Exam (pertinent points) ƒ Vitals T 99.4 BP 123/79 P 91 O2sat 98% ƒ HEENT Dry mucous membranes ƒ Abdomen Gravid, Distended, marked RUQ and moderate diffuse abdominal tenderness, no rebound or guarding, negative Rovsing’s sign Pertinent Labs ƒ WBC 13.9 ƒ UA negative ƒ LFTs normal ƒ Amylase and Lipase normal Ms.O’s story continues 4 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Acute Appendicitis Acute Cholecystitis Intestinal Obstruction Nephrolithiasis Gastroenteritis *Special concerns during pregnancy* Ligamentous Laxity, Preterm Labor, Abruption, Miscarriage, and Ovarian Torsion DDX: abdominal pain in the pregnant patient 5 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Netter,2003 RLQ Anatomy Female pelvic anatomy The female abdomen and pelvis is full of structures that may develop pathology and result in abdominal pain. The history, physical, labs, and studies, help narrow the list of possible offenders. 6 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Anatomy of the appendix The vermiform appendix projects off of the cecum distal to the ileocecal valve. http://z.about.com/d/p/440/e/f/7028.jpg 7 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Definition Inflammation of the appendix due to obstruction by fecalith (appendicolith), lymphoid hyperplasia, or rarely, parasite, foreign bodies, or tumor Classic Presentation Peri-umbilical (visceral) pain followed by nausea and vomiting that ultimately migrates to become right lower quadrant (somatic) pain within 24 hours Associated Findings Rovsing’s sign, leukocytosis (>10,000) , tachycardia, hypotension Incidence during Pregnancy 0.05-0.07% (similar to general population) Acute Appendicitis 8 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Diagnostic Challenges in Pregnancy www.pamf.org/pregnancy/first www.pamf.org/pregnancy/thirdwww.pamf.org/pregnancy/second Anatomic Changes ƒ Enlarging uterus displaces appendix cephalad ƒ Separation of visceral & parietal peritoneum (impaired pain localization) Physiologic Changes ƒ Masking of leukocytosis (normal pregnancy WBC range 6-16,000) ƒ Increased blood volume blunts tachycardia and hypotension Creasy, 1984. 1st trimester 2nd trimester 3rd trimester 9 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD A pregnant woman with appendicitis ƒ Increased risk of perforation (43%) compared to general population 4-19%) ƒ If perforation occurs, risk of fetal mortality increases from 1.5% to up to 35% Appendectomy during pregnancy ƒ Usual risks of surgery ƒ Spontaneous abortion ƒ Preterm labor ƒ premature delivery Appendicitis in pregnancy: a risky situation Levine, 2006 and Augustin, 2006 10 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Imaging studies in appendicitis Key Findings ƒ Diameter > 7mm ƒ Fluid filled structure ƒ Wall thickening >3mm ƒ periappendiceal fluid ƒ Appendicolith ƒCT Scan Sensitivity 94% Specificity 95% ƒ Ultrasound Sensitivity 86% Specificity 81% ƒ MRI Sensitivity 100% Specificity 94% Humes and Simpson,2006 and Pedrosa et al, 2006 11 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Frontal Plain Film Appendicolith (Lateral to S.I. Joint) http://www.learningradiology.com Companion Patient #1: Appendicolith 12 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Companion Patients #2 and 3: Appendicitis on CT Scan Mullins, Rhea and Novelline, 2003 Blind tip Appendicolith fat stranding Findings: Image from PACS Exposure to ionizing radiation. Drawback: 11 mm appendix CT with colon contrast CT with oral contrast 13 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Graded-Compression Sonography Benefits: readily available and no associated ionizing radiation Drawbacks: operator dependent, pain and/or gravid uterus may hinder exam, a normal or perforated appendix may not be visualized MRI Benefits: no ionizing radiation and excellent sensitivity and specificity Drawbacks: limited availability, contraindications, cost, claustrophobia Appendiceal Imaging modalities during Pregnancy 14 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Companion Patients #4 and 5: Appendicitis on Graded-Compression Sonography ƒ Compress abdomen with high resolution transducer ƒ Identify terminal ileum ƒ Scan for cecal tip and adjacent appendix How is it performed? ƒ Enlarged, fluid-filled appendix ƒ Appendicolith ƒ Periappendiceal Inflammation What are the findings? Sivit and Applegate, 2003Sivit and Applegate, 2003 Transverse US Sagittal US Sagittal US 15 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Companion patient #6: Appendicitis on MRI ƒDilated tubular appendix ƒPeriappendiceal edema C=cecum, U=uterus Pedrosa et al, 2006 ƒ Oral contrast is given 1 hour prior to the study ƒ Patients are placed feet first into the magnet. ƒ Numerous images* are obtained during breath holds (20-24 seconds) ƒ Exam time takes approximately 30 minutes How is it performed? What are the findings? Coronal fat-sat SSFSE Sagittal SSFSE 16 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Advantages of MRI Protocols ƒ HASTE or SSFSE images have less motion artifact and can visualize periappendiceal fat stranding ƒ Fat-saturated T-2 images reveal high-intensity-signal inflammatory fluid ƒ Fat-saturated T-1 images reveal hemorrhage Safety of MRI in Pregnancy ƒ Radiofrequency pulses may cause tissue heating ƒ No adverse fetal affects have been linked to MRI ƒ Gadolinium is used cautiously in 2nd and 3rd trimesters, avoided in the 1st Current Practice at BIDMC ƒ Perform MRI only when ultrasound is inconclusive ƒ Use extra caution with MRI during the first trimester MRI in Pregnancy 17 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Back to our patient... ƒ Ms.0 is tearful and complaining of continuous 8/10 pain in her abdomen—worst in her RUQ ƒ She undergoes Graded-Compression Sonography 18 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Our Patient Ms.O’s Ultrasound Study No appendix is visualized. normal gallbladder normal rt. ovary (good flow on doppler) Proximal ureter 1.6 cm Rt.Hydronephrosis (common in pregnancy) Sagittal gallbladder Sagittal rt. ovary Sagittal rt. kidney Images from PACS Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Ms.O’s MRI Imaging Study Normal caliber, non-fluid filled Appendicolith (intraluminal low-signal-intensity foci) Distal Appendix Proximal Appendix Mid Appendix (site of obstruction) 9mm diameter, high-signal-intensity fluid-filled lumen Axial SSFSE Images with oral contrast Right hydronephrosis Images from PACS 20 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Coronal SSFSE with oral contrast Appendiceal Tip ƒ 8.75mm diameter (normal <7mm) ƒ High intensity fluid within lumen ƒ Minimal periappendiceal inflammation More of Ms.O’s MRI Imaging Study Image from PACS 21 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD Diagnosis Acute appendicitis involving the distal 3.5 cm Intervention Emergent appendectomy with removal of mottled appendix and perforated tip Pathologic Diagnosis Acute gangrenous appendicitis, average diameter 1.3 cm and obstructing fecalith in the lumen. Outcome Ms.O recovers gradually and is sent home on post-op day 9 in stable condition. Ms.O’s hospital course 22 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD ƒ Clinical signs and symptoms of appendicitis may be masked ƒ Delayed diagnosis may lead to perforation ƒ Surgery may lead to premature delivery and fetal loss ƒ Ultrasound is the initial imaging modality of choice ƒ MRI is performed if the ultrasound is inconclusive ƒ Key findings include an enlarged fluid-filled appendix and periappendiceal inflammation Take Home Points Appendicitis in Pregnancy 23 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD ƒ Netter F. H., M.D. Atlas of Human Anatomy, Third Edition; John T. Hansen, Ph.D. Consulting Editor. Teterboro, NJ.: Icon Learning Systems, 2003. ƒ Creasy R.K., M.D., Resnick R., M.D. Maternal-Fetal Medicine, Principles and Practice; Philidelphia, PA.: W.B. Saunders Company, 1984. ƒ Levine D., MD. Obstetric MRI. Journal of Magnetic Resonance Imaging 2006; 24: 1-15. ƒ Goran Augustin, Mate Majerovic, Non-obstetrical acute abdomen during pregnancy, European Journal of Obstetrics&Gynecology and Reproductive Biology (2006), doi:10.10/ejogrb.2006.07.052 ƒ Humes D., Simpson, J. Acute Appendicitis. BMJ 2006; 333: 530-534. ƒ Pedrosa I., M.D., Levine D., M.D., Eyvassadeh A., M.D., Siewert B., M.D., Ngo L., Ph.D., Rofsky N., M.D. MR Imaging Evaluation of Acute Appendicitis in Pregnancy. Radiology 2006; 238: 891-899. ƒ Mullins M., Rhea J, Novelline R. Review of Suspected Acute Appendicitis in Adults and Children using CT and Colonic Contrast Material. Seminars in Ultrasound, CT, and MRI 2003; 24: 107-113. ƒ Sivit C., Applegate K. Imaging of Acute Appendicitis in Children. Seminars in Ultrasound, CT, and MRI 2003; 24: 74-82. ƒ Brown M., Birchard K., Smelka R. Magnetic Resonance Evaluation of Pregnant Patients with Acute Abdominal Pain. Seminars in Ultrasound CT and MRI 2005; 26: 206-211. ƒ http://z.about.com/d/p/440/e/f/7028.jpg ƒ http://www.learningradiology.com/images/giimages1/gigallerypages/appendicolith.jpg ƒ http://www.pamf.org/pregnancy/first/fetal.html References 24 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD ƒ Gillian Lieberman, MD ƒ Pamela Lepkowski ƒ Larry Barbaras, Webmaster Acknowledgements 25 Megan Browning, HMSIII Gillian Lieberman, MD Megan Browning, HMSIII Gillian Lieberman, MD any ?’s Baby O. courtesy of BIDMC PACS �Abdominal Pain in a Pregnant Patient Slide Number 2 Slide Number 3 Slide Number 4 Slide Number 5 Anatomy of the appendix Slide Number 7 Slide Number 8 Slide Number 9 Slide Number 10 Slide Number 11 Slide Number 12 Slide Number 13 Slide Number 14 Slide Number 15 Slide Number 16 Back to our patient... Slide Number 18 Slide Number 19 Slide Number 20 Slide Number 21 Slide Number 22 Slide Number 23 Slide Number 24 Slide Number 25