Tag: pelvic ultrasound

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Case 66: Rapid Diagnosis of Hemorrhagic Ovarian Cyst in a Reproductive-age Patient

Brigid Larkin, Colleen Campbell

A 20-year-old female with no significant past medical history presented to the emergency department with 5 days of focal right lower quadrant abdominal pain progressively worsening in severity. The pain was constant and non-radiating, accompanied by generalized abdominal discomfort, nausea, and intermittent light-headedness. Her last menstrual period occurred 3 weeks prior. She denied vaginal bleeding, dysuria, hematuria, constipation, diarrhea, or hematochezia. Past surgical history was unremarkable. Family history was notable for uterine fibroids in her mother and maternal grandmother.

Vital signs: BP 118/67 mmHg | Pulse 89 | Temp 99.1 Fº | Resp 16 | SpO2 100%

Physical exam:  The patient was well-appearing but uncomfortable. Her abdomen was soft with mild distention and diffuse tenderness, with voluntary guarding on deep palpation. No CVA tenderness was appreciated.

Labs: Hgb 11.3, WBC 18.7, Negative urine pregnancy test, lactate WNL, Urinalysis negative

Bedside Ultrasound:

  • RUQ/Biliary: no evidence of cholelithiasis or cholecystitis
  • Appendix: no evidence of appendicitis
  • Pelvic/Transvaginal: large adnexal cyst structure (~5cm) with internal echoes suggestive of a hemorrhagic cyst; free fluid visualized in the pelvis. No evidence of intrauterine pregnancy.
Figure 1. Ovary with Adnexal Mass

A CT scan was ordered which showed a hemorrhagic ovarian cyst with mild hemoperitoneum. OBGYN was consulted and recommended no acute surgical intervention. They recommended fluids and outpatient follow-up with repeat ultrasound of right ovarian cyst at 6 weeks.

Discussion:

Acute pelvic pain in reproductive-age women represents a broad differential diagnosis including appendicitis, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, and ruptured ovarian cyst. Point-of-care ultrasound (POCUS) serves as an essential early diagnostic tool because it is rapid, radiation free, and able to identify adnexal pathology and free intraperitoneal fluid even before CT imaging is obtained.

Hemorrhagic ovarian cysts are typically functional cysts resulting from bleeding into a corpus luteum or follicular cyst. Sonographically, they often demonstrate reticular internal echoes, a lacy or fibrin-strand appearance, or a mixed echogenicity depending on the age of the clot.1,2 Cyst rupture is more likely if the cyst is 5 cm or greater.  Color flow can be used to evaluate for active extravasation.  Symptoms accompanying rupture include sudden severe abdominal pain or near syncope.  Free fluid may be present in the pelvis, with swirling sometimes visible for brisk bleeds. Transvaginal POCUS is highly sensitive for detecting free intraperitoneal fluid of as little as 10cc, making it a valuable adjunct when evaluating patients with suspected hemoperitoneum.3

In this case, the adnexal mass with internal echoes and associated free fluid on POCUS raised concern for a hemorrhagic cyst with rupture, prompting timely gynecologic consultation and confirming findings on CT.

Hemorrhagic cysts frequently mimic appendicitis due to overlapping localization of pain and peritoneal irritation. Studies show that up to 20-30% of reproductive-age women evaluated for appendicitis ultimately have a gynecologic etiology, underscoring the importance of early pelvic imaging.4 The patient’s leukocytosis and focal RLQ tenderness initially broadened the differential, but POCUS rapidly narrowed the diagnosis.

Most hemorrhagic ovarian cysts are self-limited and managed conservatively with pain control and follow-up imaging.5 Indications for intervention include hemodynamic instability, large-volume hemoperitoneum, or concern for ovarian torsion. In this case, the patient remained stable, with moderate hemoperitoneum on CT and no evidence of torsion or persistent bleeding.  Oftentimes with cyst rupture, repeat CBC is indicated to evaluate for ongoing blood loss.

POCUS is a recommended first-line tool in the evaluation of acute pelvic pain in the emergency department. The American College of Emergency Physicians notes the utility of pelvic ultrasound for identifying adnexal masses, cyst rupture, free fluid, and excluding ectopic pregnancy in reproductive-age females.6  While transvaginal ultrasound is the standard of care for evaluation of the ovaries, transabdominal POCUS is highly effective in early triage and in resource-limited or time-sensitive settings.

This case demonstrates the significant diagnostic value of POCUS in identifying adnexal pathology early in the clinical course, guiding appropriate consultation, and avoiding unnecessary CT radiation. Recognition of characteristic sonographic features of hemorrhagic ovarian cysts empowers emergency physicians to differentiate benign from life-threatening causes of pelvic pain.

References:

  1. Jain, K. A. (2002). Sonographic spectrum of hemorrhagic ovarian cysts. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, 21(8), 879–886. https://doi.org/10.7863/jum.2002.21.8.879
  2. Talat, H., Tul-Sughra Murrium, S. K., Suleman, T., Tallat, E., Naveed, F., Hussain Shah, S. J., & Hina Zulfiqar, G. E. (2022). Sonographic Findings of a Gynecological Cause of Acute Pelvic Pain – A Systematic Review. Journal of Ultrasonography, 22(90), e183–e190. https://doi.org/10.15557/jou.2022.0030
  3. Kimura, A., & Otsuka, T. (1991). Emergency center ultrasonography in the evaluation of hemoperitoneum: A prospective study. The Journal of Trauma, 31(1), 20–23. https://doi.org/10.1097/00005373-199101000-00004
  4. Andersson, R. E. B. (2004). Meta-analysis of the clinical and laboratory diagnosis of appendicitis. The British Journal of Surgery, 91(1), 28–37. https://doi.org/10.1002/bjs.4464
  5. Bottomley, C., & Bourne, T. (2009). Diagnosis and management of ovarian cyst accidents. Best Practice & Research. Clinical Obstetrics & Gynaecology, 23(5), 711–724. https://doi.org/10.1016/j.bpobgyn.2009.02.001
  6. American College of Emergency Physicians. Emergency Ultrasound Guidelines. ACEP;2016. https://www.acep.org/siteassets/sites/acep/media/ultrasound/pointofcareultrasound-guidelines.pdf
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Case 59: Abdominal and Pelvic Pain

Eli Tran, Elaine Yu

20YO female presented to the emergency department with 4-5 days of pelvic/abdominal pain, with abrupt worsening one day prior while resting. Her pain was sharp, sudden, and improved with ED analgesics. No dizziness, lightheadedness, or vaginal bleeding. LMP 4 weeks prior. She was not using birth control.

Exam: Vital signs were within normal limits. She appeared uncomfortable but non-toxic. She had pelvic and lower abdominal tenderness without guarding or rebound. No focal cardiopulmonary or neurologic abnormalities.

Labs

  • WBC 14.6 to 18.7 with neutrophilia.
  • Hgb 11.3
  • hCG <1.
  • Lactate 1.4.
  • Coags normal.
  • UA: SG 1.042, ketonuria, mild proteinuria; no hematuria.

Bedside pelvic ultrasound was performed with the following images:

Figure 1: Transabdominal ultrasound with free fluid in the pelvic region.

Figure 2: Transvaginal ultrasound with pelvic free fluid.

Figure 3: Transvaginal ultrasound with two cystic structures in the area of the left ovary.

ED Course

A formal pelvic ultrasound was ordered.

Figure 4: Pelvic free fluid with irregular cystic structure in area of left ovary consistent with a hemorrhagic cyst.

A CT scan of the abdomen and pelvis was ordered for concern of active hemorrhage. The CT showed showed a ruptured hemorrhagic ovarian cyst without active bleeding. There was also a finding of an absent left kidney with compensatory hypertrophy of the right kidney.

The patient remained hemodynamically stable and responded to analgesia. Her repeat hemoglobin after several hours was 12.4. Gynecology was consulted and recommended conservative management with 6-8 week follow-up.

The solitary kidney was an incidental finding unrelated to the current presentation. There was no hydronephrosis, obstruction, or infection. Renal function was preserved.

Discussion

The patient’s clinical picture and imaging are most consistent with a ruptured hemorrhagic ovarian cyst, a common cause of sudden pelvic pain with hemoperitoneum in reproductive-age women. Hemodynamic stability and absence of active bleeding support conservative management.

The incidentally detected solitary kidney is important to document but does not alter acute ED management. Most solitary kidneys identified incidentally in emergency imaging are congenital1-3 (unilateral renal agenesis or multicystic dysplastic kidney) or acquired (post-nephrectomy for tumor, trauma, or severe infection). Congenital solitary kidney accounts for the majority of incidental cases, often presenting with compensatory hypertrophy of the remaining kidney, as seen here.

Solitary kidney is associated with an increased long-term risk of CKD and hypertension, with some studies demonstrating >3-fold increased risk compared to individuals with two kidneys. The risk is highest in patients with vesicoureteral reflux or ureteropelvic junction obstruction, which occur in 17–48 percent of congenital cases. Cross-sectional imaging4-5 is generally sufficient for identifying and characterizing a solitary kidney; additional imaging (e.g., nuclear scintigraphy) is rarely required unless ectopic tissue or uncertain anatomy is suspected.

ED disposition: home with Gynecology and Nephrology follow-up

References

  1. Kim S, Chang Y, Lee YR, et al. Solitary Kidney and Risk of Chronic Kidney Disease. Eur J Epidemiol. 2019;34(9):879-888.
  2. Westland R, Schreuder MF, van Goudoever JB, et al. Clinical Implications of the Solitary Functioning Kidney. CJASN. 2014;9(5):978-986.
  3. Urisarri A, Gil M, Mandiá N, et al. Risk Factors for CKD in Congenital Solitary Kidney. Medicine. 2018;97(32):e11819.
  4. Krill A, Cubillos J, Gitlin J, Palmer LS. Abdominopelvic Ultrasound as a Diagnostic Tool for Solitary Kidney. J Urol. 2012;187:2201-2204.
  5. Grabnar J, Rus RR. Is Renal Scintigraphy Necessary in Diagnosis of Congenital Solitary Kidney? Pediatr Surg Int. 2019;35:729-735.
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Case 27: Ectopic Pregnancy

A 43 year old female with no past medical history presents to the Emergency Department (ED) with lower abdominal pain for the last three hours. She says she knows she is pregnant from a home pregnancy test, but has not had any appointment with obstetrics and has not had an ultrasound yet. She denies any vaginal bleeding.  

Vitals: BP 120/65 mmHg, HR 85, O2 100% on RA.

She is comfortable appearing, her abdominal exam shows mild tenderness to palpation diffusely in the lower abdomen with no rebound and her pelvic exam shows a closed os with no bleeding.

Her point-of-care urine pregnancy test is positive.

You perform a trans-abdominal bedside ultrasound, what do you see?  What are your next steps?

pelvic free fluid

ectopic

positive fast

Answer and Learning Points

Answer:

The first image is a transverse view of the uterus that shows free fluid in the retcouterine pouch (Pouch of Douglas). The second image is another transverse view of the uterus that also shows free fluid in the rectouterine pouch and then fans through to scan the uterus and adnexa. From what we see there is no gestational sac in the uterus and if you look closely there appears to be a heterogenous structure in the left adnexa. The final view is a FAST view in the right upper quadrant, looking at Morrison's Pouch. We see free fluid here as well. 

These findings - a positive pregnancy test, free fluid in the pelvis and no clear intra-uterine pregnancy indicates an ectopic pregnacny until proven otherwise. The next step should be a tranvaginal ultrasound and consultation with Gynecology. 

Conclusion and Learning Points:

The transvaginal ultrasound revealed a left-sided ectopic pregnancy, as seen in the following picture. They identified a fetal pole and even a fetal heart rate in the ectopic pregnancy. The patient was taken to the operating room with Gynecology and had a salpingectomy without complications. She was discharged home three days later. 

Learning Points:

    • Any female of child-bearing age with abdominal pain should be considered for ectopic pregnancy
    • Ultrasound findings in ectopic pregnancy will not always show the ectopic itself, but rather findings suggestive of ectopic:
      • Intra-abdominal free fluid
      • No clear intra-uterine pregnancy (patients with ectopic will sometimes still have a "pseudo-gestational sac" that appears similar to a gestational sac, but there will be no yolk sac or fetal pole)
      • Heterogenous adnexal structure
    • You should not wait for B-HCG measurements to consider ectopic pregnancy, case reports have shown ectopic pregnancies with minimal HCG levels can still rupture (1)

References

1. Fu, Joyce, et al. Rupture of ectopic pregnancy with minimally detectable beta-human chorionic gonadotropin levels: a report of 2 cases. J Reprod Med. 2007 Jun;52(6):541-2.

This post was written by Charles Murchison MD and Anthony Medak MD, with further editing by Amir Aminlari MD.

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