Free Fluid In Pelvis Research Articles

Spontaneous Rupture of a Fibrolamellar Variant Hepatocellular Carcinoma in an Innocent Liver

Introduction: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a unique variant of hepatocellular carcinoma. The majority of cases present with nonspecific symptoms like vague abdominal pain, weight loss and fatigue. Ruptured FL-HCC occurs rarely and mortality in the acute phase is very high. We report a rare case of a ruptured FL-HCC successfully managed with transarterial embolization for hemostasis. Case: A 37-year-old male previously in good health presented with a severe, sharp epigastric pain that started one hour prior to the presentation. He denied trauma, fever, nausea, vomiting, diarrhea. Tenderness in the epigastrium was noted, with no palpable masses, guarding or rigidity. His blood pressure and pulse were 159/105 mmHg and 105 beats/min. Platelets and coagulation parameters were within normal limits, while hemoglobin of 12 g/dL, wbc of 11 k/mL and elevated transaminases (AST of 214 IU/L, ALT of 138 IU/L, ALP 98 IU/L, T.Billi 1.5 mg/dL) were noted. Abdominal CT scan with contrast revealed an 8 cm lobulated mass with central hypodensity in the left hepatic lobe with perilesional blood and free pelvic fluid, indicating tumor rupture (figure 1). CT angiography showed tumor neovascularization from a branch of the left hepatic artery which was embolized using transarterial gelfoam. Liver MRI (figure 2) and biopsy (figure 3) were consistent with fibrolamellar variant hepatocellular carcinoma. Hepatitis serologies and AFP levels were unremarkable. After 4 days, as the symptoms resolved and the lab results were stable, patient was discharged and underwent a left hepatectomy 3 weeks later. Discussion: FL-HCC occurs commonly in the left lobe of a young and non-cirrhotic liver. Typically cross sectional imaging reveals a lobulated mass with well-defined margins, areas of hypervascularity and a central calcified scar. Histologic appearance is characterized by eosinophilic polygonal shaped cells separated by lamellar fibrosis. Surgical resection is the treatment of choice with better outcome when compared to conventional HCC. Disease recurrence after complete surgical resection is however high in the first 5 years. Tumors > 5 cm in size are at high risk for rupture with high mortality and recurrence rates secondary to significant spillage of tumor. While an emergency hepatectomy is preferred in unstable patients, those that are hemodynamically stable can undergo radiologic transarterial embolization for hemostasis followed by staged hepatectomy.Figure: Axial section of CT Abdomen and Pelvis with IV contrast: (on the left) An 8 x 7 cm heterogeneous lobulated mass with central hypo density in the left hepatic lobe with arrow pointing perilesional blood concerning for tumor rupture. (on the right) An arrow pointing hyperdensity fluid surrounding urinary bladder likely blood from tumor rupture.Figure: MRI of the abdomen with liver protocol post embolization showing a 7.7 x 6.6 cm well circumscribed expansile lesion in left lobe of liver with global hypo T2 signal intensity with areas of hyper T2 signal intensities as well as central stellate shaped scar of low T2 signal intensity.Figure: Histopathologic examination of haematoxylin and eosin stained liver biopsy specimen (on the left) under high power magnification showing tumor cells with hepatocellular appearance: large polygonal cells, ample eosinophilic cytoplasm, with focal bile pigment, marked nuclear atypia, and Intranuclear pseudoinclusions. (on the right) under low power magnification showing tumor cells separated by hyaline collagen.

Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients

ObjectiveTo investigate the accuracy of torsion diagnosis in the pediatric and adolescent population. MethodsThis retrospective study included 87 patients <18years who presented with acute pelvic pain and were operated for suspected adnexal torsion from January 2009 to September 2016. ResultsAdnexal torsion was found in 53 of 87 (60.9%) cases operated for suspected torsion. The rate of accurate torsion diagnosis was significantly higher among pre-menarchal (21/21, 100%) compared with post-menarchal girls (32/66, 48.5%) (p<0.001). Patients with torsion were more likely to report nausea or vomiting (73.6% compared with 32.3%, p<0.001) and had higher rates of peritoneal irritation signs on exam (15.1% compared with 0.0%, p=0.02). On the pre-operative ultrasound, patients with torsion were characterized by higher rates of enlarged ovary showing signs of edema (49.1% compared with 8.8%, p<0.001) and free pelvic fluid (45.3% compared with 17.6%, p<0.001). In post-menarchal girls without adnexal torsion, the leading diagnosis was hemorrhagic corpus luteum cyst (found in 18/33, 78.3%) cases. ConclusionsVarious clinical and ultrasound findings may point to the correct diagnosis of torsion in the pediatric and adolescent population. However, none of the clinical and ultrasound characteristics are sufficient to confirm or disprove the pre-operative diagnosis, and young patients with the clinical suspicion of adnexal torsion should undergo laparoscopy. Level of evidenceLevel II. Type of studyClinical retrospective study.

Diverticulitis Diagnosed in the Emergency Room: Is It Safe to Discharge Home?

Inpatient treatment of patients with colon diverticulitis represents a significant financial and clinical burden to the health care system and patients. The aim of this study was to compare patients with diverticulitis in the emergency department (ED), who were discharged to home vs admitted to the hospital. We reviewed all patients evaluated in the ED of a metropolitan health system, with the primary diagnosis of diverticulitis (ICD-9 562.11), from 2010 through 2012. Only patients diagnosed with CT and those with follow-up were included. We identified 240 patients; 132 (55%) were women and mean age was 59.1 years (SD 16.1 years). Imaging findings included extraluminal air (21%), pericolic or pelvic abscess (12%), free fluid (16%), and pneumoperitoneum (6%). One hundred forty-four (60%) were admitted to the hospital and 96 (40%) were discharged to home on oral antibiotics. Patients admitted to the hospital were more likely to be older than 65 years (p= 0.0007), have a Charlson comorbidity score ≥ 2 (p= 0.0025), to be on steroids or immunosuppression (p= 0.0019), and have extraluminal air (p < 0.0001) or diverticular abscess (p < 0.0001) on imaging. Median follow-up for all patients was 36.5 months (interquartile range 25.2 to 43 months). Among patients discharged from the ED, 12.5% returned to the ED or were readmitted within 30 days, with only 1 patient (1%) requiring emergency surgery, but not until 20 months later. Patients admitted to the hospital had similar rates of readmission (15%; p= 0.65). Patients diagnosed with uncomplicated diverticulitis in the emergency room can be safely discharged home on oral antibiotics, as long as CT findings are included in the decision-making process. Patients with complicated diverticulitis on CT scan should be admitted to the hospital with surgical consultation.

Multimodality imaging findings of massive ovarian edema in children.

Massive ovarian edema is a rare benign condition that predominantly affects childbearing women as well as preadolescent girls. It is thought to result from intermittent or partial torsion of the ovary compromising the venous and lymphatic drainage but with preserved arterial supply. The clinical features of massive ovarian edema are nonspecific and can simulate tumors, leading to unnecessary oophorectomy. To demonstrate imaging features that should alert radiologists to consider the diagnosis of massive ovarian edema preoperatively so that fertility-sparing surgery may be considered. We identified five girls diagnosed with massive ovarian edema at pathology. Presenting symptoms, sidedness, imaging appearance, preoperative diagnosis, and operative and histopathological findings were reviewed. Age range was 9.6-14.3years (mean age: 12.5years). Common imaging findings included ovarian enlargement with edema of the stroma, peripherally placed follicles, isointense signal on T1-W MRI and markedly hyperintense signal on T2-W MRI, preservation of color Doppler flow by US, and CT Hounsfield units below 40. The uterus was deviated to the affected side in all patients. Two of the five patients had small to moderate amounts of free pelvic fluid. Mean ovarian volume on imaging was 560mL (range: 108-1,361mL). While the clinical presentation of massive ovarian edema is nonspecific, an enlarged ovary with stromal edema, peripherally placed follicles and preservation of blood flow may be suggestive and wedge biopsy should be considered intraoperatively to avoid unnecessary removal of the ovary.

A lady with repeated vomiting - unexpected diagnosis

Background: Vomiting is a symptom commonly encountered in emergency settings, with many differential diagnoses. In the following case, the diagnosis was nearly missed and the outcome could have been critical. Methods: A case study was performed, supported by literature review. A 32 year-old lady presented to the Emergency Department with repeated vomiting for one day. She has had epigastric discomfort for several days. Her blood pressure was 119/74 mmHg, heart rate 118/minute, and she was afebrile. She had been under the in-vitro fertilisation program and received human chorionic gonadotrophin, oocyte retrieval and embryo transfer 8, 6, and 3 days respectively prior to presentation. On examination, her abdomen was soft, non-tender. Urinary pregnancy test was negative. Her sodium level was 131 mmol/l, Hb 17.0 g/dL, white cell count 20.5 × 10*9/L, and platelet 485 × 10*9/L. The rest of the renal and liver functions and amylase, were normal. She was admitted to the Emergency Ward with a working diagnosis of gastritis. On reassessment, her abdomen was noted to be slightly distended although no tenderness or guarding was elicited. Ovarian hyperstimulation syndrome was suspected, and gynaecology was consulted for further evaluation. Results: Transvaginal ultrasound scan showed a normal-sized uterus with thickened endometrium and no intrauterine sac. Both ovaries were enlarged, left ovary 6.1 × 4.3 cm and right ovary 5.0 × 5.3 cm. Significant pelvic free fluid was present. The diagnosis was confirmed to be early ovarian hyperstimulation syndrome. Ovarian hyperstimulation syndrome is an iatrogenic complication from assisted reproduction technology. Following gonadotropin therapy, this condition usually develops several days after oocyte retrieval or assisted ovulation, with ovarian enlargement due to multiple ovarian cysts. Complications include ascites, haemoconcentration, hypovolaemia, and electrolyte imbalances. Conclusion: Emergency physicians should consider ovarian hyperstimulation syndrome in patients who had received assisted reproduction presenting with repeated vomiting.

Pelvic Inflammatory Disease: Multimodality Imaging Approach with Clinical-Pathologic Correlation.

Pelvic inflammatory disease (PID) is a common medical problem, with almost 1 million cases diagnosed annually. Historically, PID has been a clinical diagnosis supplemented with the findings from ultrasonography (US) or magnetic resonance (MR) imaging. However, the diagnosis of PID can be challenging because the clinical manifestations may mimic those of other pelvic and abdominal processes. Given the nonspecific clinical manifestations, computed tomography (CT) is commonly the first imaging examination performed. General CT findings of early- and late-stage PID include thickening of the uterosacral ligaments, pelvic fat stranding with obscuration of fascial planes, reactive lymphadenopathy, and pelvic free fluid. Recognition of these findings, as well as those seen with cervicitis, endometritis, acute salpingitis, oophoritis, pyosalpinx, hydrosalpinx, tubo-ovarian abscess, and pyometra, is crucial in allowing prompt and accurate diagnosis. Late complications of PID include tubal damage resulting in infertility and ectopic pregnancy, peritonitis caused by uterine and/or tubo-ovarian abscess rupture, development of peritoneal adhesions resulting in bowel obstruction and/or hydroureteronephrosis, right upper abdominal inflammation (Fitz-Hugh-Curtis syndrome), and septic thrombophlebitis. Recognition of these late manifestations at CT can also aid in proper patient management. At CT, careful assessment of common PID mimics, such as endometriosis, adnexal torsion, ruptured hemorrhagic ovarian cyst, adnexal neoplasms, appendicitis, and diverticulitis, is important to avoid misinterpretation, delay in management, and unnecessary surgery. Correlation with the findings from complementary imaging examinations, such as US and MR imaging, is useful for establishing a definitive diagnosis. (©)RSNA, 2016.

Pelvic Free Fluid in Asymptomatic Pediatric Blunt Abdominal Trauma Patients: A Case Series and Review of the Literature

BackgroundWith focused assessment with sonography in trauma (FAST) examinations being performed more commonly on pediatric trauma patients, emergency providers will encounter a positive FAST examination in patients with benign abdominal examinations. This poses a diagnostic dilemma for the provider when deciding whether to obtain a computed tomography (CT) scan of the abdomen/pelvis, observe the patient, or admit the patient. Case ReportWe report a series of pediatric patients involved in blunt abdominal trauma who had small pelvic free fluid on FAST but a benign abdominal examination. Three patients were managed without CT scan and 2 with CT scan. All patients did well and were discharged home. Why Should an Emergency Physician Be Aware of This?Free intra-abdominal fluid may be physiologic in both male and female pediatric patients. Clinical examination and hemodynamic stability should be taken into account when deciding to order a CT scan. We review the literature and highlight new protocols that may decrease CT utilization and ionizing radiation exposure, though further studies in this specific population are needed.

Quick Consult

FigureFigureFigureA 19-year-old G1P0 woman is transferred from a nearby urgent care with vaginal bleeding. She reported her first positive home pregnancy test was two weeks earlier, and she has not yet been seen by an obstetrician. Her last menstrual period was approximately 14 weeks prior. She first noticed the vaginal bleeding 10 days earlier, but it resolved, and today she began spotting again. She is without fever or urinary complaints. She denies antecedent trauma or domestic violence. Her vitals are within normal limits, her abdominal exam is benign, and her pelvic exam reveals a closed os with scant blood in the vault and no cervical motion tenderness. Her bedside ultrasound is shown. You see clear intrauterine contents but have difficulty visualizing fetal heart rate or movements. (Image 1.) There is no significant free pelvic fluid in the cul-de-sac and the endomyometrial mantle thickness is adequate. A beta-HCG level returns at 67,000 mIU/mL. A consultative pelvic ultrasound was performed and demonstrated heterogeneous material within the endometrial cavity that may relate to failed pregnancy. What should you do next? Does this patient warrant additional workup in the ED? Find the diagnosis and case discussion on the next page. Diagnosis: Molar Pregnancy Obstetrics was consulted, and this patient was discharged and returned for a scheduled dilation and curettage (D&C). Tissue was sent for pathology and ultimately revealed a complete hydatidiform mole. Hydatidiform moles are a gestational trophoblastic disease that result from abnormal fertilization. A complete molar pregnancy occurs when an empty egg is fertilized by two sperm, creating a diploid (46, XX or 46, XY) karyotype. The resulting tissue develops into a mass of swollen chorionic villi in grapelike structures. A small percent of these moles will become invasive or give rise to choriocarcinomas. The incidence of complete hydatidiform moles is about one in 2000 pregnancies in the United States, with increased rates in women under 20 or over 40. (Robbins Basic Pathology. Philadelphia: Elsevier Saunders; 2013, 735.) Despite the traditionally taught clinical presentation for molar pregnancies — excessive uterine size for dates, anemia, hyperemesis, preeclampsia, and clinical hyperthyroid state — the vast majority of patients will be asymptomatic or report vaginal bleeding without other systemic manifestations. (Arch Gynecol Obstet 2000;264[1]:33.) The classic ultrasound description of a “cluster of grapes” or a “snowstorm” is present in less than two-thirds of molar pregnancies in the first trimester. (J Ultrasound Med 1999;18[9]:589.) Evaluating Complications Point-of-care obstetric ultrasound is commonly used to evaluate first-trimester complications. The goal of this should be to identify a viable intrauterine pregnancy and exclude first-trimester emergencies such as ectopic pregnancies. (ACEP Emergency Ultrasound Documents; http://bit.ly/1MpP0WP.) Failure to identify a clear fetal structure or fetal heart rate should prompt referral for consultative ultrasounds and follow-up with an obstetrician. Final diagnosis of molar pregnancies is achieved by D&C with tissue pathology, after which quantitative HCG levels are trended to ensure complete evacuation of the mole. The patient sought follow-up care in the gynecology clinic and had weekly beta-HCG levels drawn to ensure appropriate downtrending until undetectable. Thyroid studies and a chest radiograph to screen for cardiopulmonary manifestations attributable to trophoblastic embolization or thyrotoxicosis were also unremarkable. She was counseled about the importance of not becoming pregnant until her molar pregnancy resolved because a new pregnancy would complicate management. A Paragard intrauterine device was placed at the time of the D&C to guard against this. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

A Case of Heterotopic Pregnancy

We are presenting a case report of heterotopic pregnancy, which is diagnosed during ultrasound examination of a gravid woman, 23 year old, referred from outpatient department. Heterotopic pregnancy is a rare obstetrics phenomenon and carries a significant natural morbidity and mortality due to risk of rupture of the ectopic pregnancy. Clinicians and sonographers may fall into a false sense of security when an intrauterine gestational sac is identified. This results in inadequate inspection of the adnexae and remaining structures during ultrasonography despite a strong initial clinical suspicion of ectopic pregnancy. Hence, a thorough ultrasonographic examination is needed in managing these patients, especially when there is a high suspicion of ectopic pregnancy or in the presence of pelvic free fluid even when an intrauterine pregnancy is identified. DOI: http://dx.doi.org/10.3329/cmoshmcj.v14i1.22888 Chatt Maa Shi Hosp Med Coll J; Vol.14 (1); Jan 2015; Page 64-66

Delayed presentation of uterine rupture postpartum

FIGURE 2 Computed tomography scan of pelvis: transverse view Case notes A 32-year-old G2P1 with a history of cesarean delivery had an uncomplicated vaginal delivery at term. Two days after giving birth, she developed high-grade fever, tachycardia, hypotension, lower abdominal pain, and right flank pain. Computed tomography (CT) scan at that time revealed bladder wall thickening and a small amount of pelvic free fluid. She was started on broad-spectrum antibiotics for suspected pyelonephritis and sepsis. However, urine cultures were

PMM.19 Sertoli Leydig Cell Tumour in Pregnancy

BackgroundSex cord stromal tumours make up less than 0.2% of tumours in the ovaries and about 1% of ovarian malignancies during pregnancy. Their unpredictability makes counselling, management, and prognosis challenging.This...

Bilateral Torsioned Dermoids Presented With Acute Abdomen

A 21 year old woman admitted to our emergency department with progressive low abdominal pain started in a few hours. She had no surgical, clinical or family history before. Physical examination revealed tenderness, defence, rebound in bilateral lower quadrants and a palpable mass located in right adnexial region. Her complete blood account and biochemical profile were in normal limits. Contrast enhanced computer tomography of abdomen showed bilateral ovarian masses containing fat attenuation which was characteristic for dermoid cysts (Figure 1a-b) and free pelvic fluid. Additionally in right dermoid, there was hyperattenuating debris inside and a twisted pedicle (Figure 1b). This appearance was suggestive for adenexial torsion. Under general anaesthesia surgery was performed, bilateral torsioned dermoids and gangrene were found. Postoperative period was uneventful and patient discharged a few days later. Intratumoral fat attenuation is typical CT finding of dermoids that found 93% of cases. In some cases a floating mass of hair that called Rochitansky nodule, teeth or calcification could be detected inside of the mass. Large cystic teratomas that over 11 cm could lead to torsion of adnex. No vascular supply on colour Doppler and detection of the twisted or distended pedicle on CT imaging is suggestive for torsion (1, 2).

Clinical Significance of a Small Amount of Isolated Pelvic Free Fluid at Multidetector CT in Male Patients after Curative Surgery for Gastric Carcinoma

Clinical Significance of a Small Amount of Isolated Pelvic Free Fluid at Multidetector CT in Male Patients after Curative Surgery for Gastric Carcinoma

Treatment monitoring with 18F-FDG PET/CT in a patient with peritoneal tuberculosis

A 71-year-old man with a history of spinocellular carcinoma of the right cheek presented with a 2-month history of mild abdominal pain and persistent slight fever. Blood sampling data showed signs of inflammation (C-reactive protein 6.78 mg/ml). Tumour marker levels were normal. Abdominal ultrasonography showed a small amount of perihepatic and pelvic free fluid, increased mesenteric echogenicity and mesenteric lymphadenopathy. 18 F-FDG PET/CT showed increased tracer accumulation in the entire abdominal region (a), associated with the peritoneum and diaphragm (b). CT revealed uniform thickening of the peritoneum (c). Lung findings were unremarkable. Testing of the ascites fluid for acid-resistant bacilli performed twice was negative. Cytological examination revealed mesothelial hyperplasia with inflammatory changes. Diagnostic laparoscopy showed multiple nodules spread throughout the peritoneum. Histology revealed caseating granulomas with epithelioid and Langerhans-type giant cells. Ziehl-Neelsen staining for acid-fast bacilli was negative, but culture of the peritoneal specimen revealed Mycobacterium tuberculosis which resulted in a final diagnosis of peritoneal tuberculosis (PT). The patient’s fever and abdominal pain gradually decreased during antituberculosis treatment. After 6 months of therapy, 18 F-FDG PET/CT showed diminished peritoneal uptake (d) and peritoneal thickening. This case indicates the clinical utility of 18 F-FDG PET/CT for detection

Medial or Lateral Location of the Whirlpool Sign in Adnexal Torsion

The whirlpool sign is used as a sonographic marker for adnexal torsion. The aims of this study were to describe the location of the whirlpool sign (lateral or medial to the ovary) and to evaluate the clinical importance of the location. Thirty patients with a confirmed surgical diagnosis of torsion and a positive whirlpool sign on sonography before surgery were included. We examined the sonographic clips of these patients. Classic signs of adnexal torsion were determined: ovarian edema, the presence of a mass, pelvic free fluid, and ovarian ischemia on Doppler imaging. The whirlpool sign was detected on grayscale and color Doppler sonography by moving the transducer to and fro along the axis of suspected torsion. Sixteen of 30 patients had right-sided torsion. Of these, 7 had a lateral whirlpool sign. All 7 of these patients had an ovarian or paraovarian mass. Nine of these 16 patients had a medial whirlpool sign. Of these, 7 had an ovarian or paraovarian mass, and 2 had no mass. Of the 14 patients with left-sided torsion, all had a medial whirlpool sign. Nine of 14 these patients had an ovarian or paraovarian mass, and 5 had no mass. The mean volume of the masses among cases with the lateral whirlpool sign was significantly greater compared to those with the medial whirlpool sign (304 versus 108 cm(3); P = .035). In 25 of 30 cases, the torsed components included the ovary. The lateral whirlpool sign is associated with enlarged masses in comparison to the medial whirlpool sign. This finding indicates the need to search meticulously for the lateral whirlpool sign in cases with enlarged masses to decide whether to operate on these patients emergently.

A rare cause of acute abdominal pain in adolescence: Hydrosalpinx leading to isolated torsion of fallopian tube

Torsion of the fallopian tube accompanying hydrosalpinx is a rare occurrence in the pediatric population. This report describes a 13year old sexually inactive girl with isolated tubal torsion due to hydrosalpinx. The girl had lower left abdominal pain for two days. The physical examination revealed left lower quadrant tenderness with a firm round anterior mass on rectal examination. Abdominal ultrasound showed left tubal enlargement with free pelvic peritoneal fluid. Magnetic Resonance Imaging (MRI) showed engorgement and dilatation of the left fallopian tube without contrast enhancement suspicious of tubal torsion. At operation, torsion of the left tube on its longitudinal axis was observed, and a salpingectomy was performed.Although rare, the diagnosis of torsion of the fallopian tube should be considered when evaluating acute abdominal pain. The earlier tubal torsion is diagnosed, the greater the likelihood of salvaging the fallopian tube.

CT appearance of the pelvis after Cesarean delivery—what is considered normal?

ObjectiveTo describe the normal computed tomography (CT) appearance of the pelvis after uncomplicated Cesarean section (C-section). Patients and methodsPelvic CT examinations of 31 patients after uncomplicated C-section were reviewed. ResultsHigher postoperative day (POD) correlated well with decreases in the uterine long axis and endometrial width but did not correlate to scar width. Full thickness defect of the uterine wall was revealed in 48% of patients. Small volumes of intrauterine gas presented in half of patients at POD 1–26. Free pelvic fluid appeared in 74%. Pelvic collections were rare and small. ConclusionThere is wide variability in pelvic CT appearance following uncomplicated C-section.

Detection of Free Intraperitoneal Fluid in Healthy Young Men

Free intraperitoneal fluid is a secondary sign of abdominal disorders. The detection of small volumes of fluid has been documented as a normal finding in women of childbearing age and also in pediatric sonography. However, the finding of free fluid in asymptomatic men has not been similarly documented by sonography. We postulate that with high-frequency linear probes, small volumes of fluid may be detected in asymptomatic men without underlying abdominal disorders. Ten healthy male volunteers underwent targeted abdominal sonographic examinations after an overnight fast and in an immediate postprandial state. The findings were documented, and representative images were saved for analysis. We found small slivers or geometric collections of fluid between bowel loops in 4 of the 10 volunteers. No obvious correlation between the detection of fluid and the nutritional or hydration status of the patient was identified. The findings suggest that small volumes of pelvic free fluid in healthy men can be normal and do not necessarily indicate underlying disorders. The role of free fluid identification as an indicator of major intra-abdominal disorders must be viewed with caution and with careful clinical correlation.

Should less motion sensitive T2-weighted BLADE TSE replace Cartesian TSE for female pelvic MRI?

ObjectivesTo prospectively compare the diagnostic performance of a non-Cartesian k-space sampling T2-weighted TSE BLADE sequence with a conventional T2-weighted TSE sequence in female pelvic organs.MethodsForty-seven patients with sonographically indeterminate adnexal masses or uterine lesions underwent sagittal BLADE and conventional TSE at 1.5 T after glucagon administration. Two radiologists independently determined their preferred sequence by rating: overall image diagnostic quality, conspicuity of the zonal anatomy and delineation of pathologies of the uterus and cervix, presence of artefacts, and of fluid in the pouch of Douglas (Wilcoxon signed rank test). Signal-to noise ratios (SNRs) and contrast-to-noise ratios (CNRs) were measured for the myometrium versus the rectus abdominis muscle (Student’s t-test).ResultsBLADE significantly (p < 0.0001) reduced motion and ghosting artefacts and showed improved conspicuity (p = 0.3/0.24), but overall image quality did not differ significantly (inter-observer agreement BLADE κ = 0.89; TSE κ = 0.84). In the majority of cases (53.2 % vs 59.6 %, respectively, κ = 0.82) radiologists preferred conventional TSE due to better image contrast (p < 0.0001) and visibility of free pelvic fluid (p ≤ 0.0001). SNR (TSE 57.5 ± 37.7; BLADE 16.6 ± 12.2) and CNR (TSE 40.4 ± 33.5; BLADE 7.2 ± 8.8) were significantly higher on conventional TSE (p < 0.0001).ConclusionsAlthough BLADE reduces motion artefacts and provides a clearer delineation of uterine zonal anatomy compared with conventional TSE, this comes at the expense of overall contrast.Main Messages• Use of BLADE may reduce T2 contrast and thus visibility of free pelvic fluid or cystic structures• Non-Cartesian sampling of k-space such as BLADE is beneficial due to less motion sensitivity• BLADE provides clearer delineation and conspicuity of uterine zonal anatomy on pelvic MRIs

Think Heterotopic: A Case Report of Heterotopic Pregnancy Detected on Thorough Ultrasonography

We present a case report of heterotopic pregnancy picked up on thorough ultrasonography in a clinically stable 22-year-old patient with low risk factors. Heterotopic pregnancy is a rare obstetrics phenomenon and carries a significant maternal morbidity and mortality due to the risk of rupture of the ectopic pregnancy. Clinicians and sonographers tend to be lulled into a false sense of security when an intrauterine gestation sac is seen. This results in inadequate inspection of the adnexae and remaining structures during ultrasonography despite a strong initial clinical suspicion of ectopic pregnancy. Hence, a thorough ultrasonography and holistic approach is needed in managing these patients, especially when there is a high suspicion of ectopic pregnancy or in the presence of pelvic free fluid even when an intrauterine pregnancy is identified. A new dictum ‘Think ectopic. If intrauterine gestation is seen, think heterotopic’ needs to be adopted. doi:10.4021/jmc779w