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Pattern 3 – Rectosigmoid Involvement – Case

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Okay, so let's look at another case

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of endometriosis and specifically

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we're going to look at rectosigmoid

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involvement in this case, but I wanted

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to show you a few more things as well.

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So remember our approach to

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endometriosis and research pattern.

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So in the last case, we looked first

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at the position of the ovaries.

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So here we've got an axial T2

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weighted sequence, and we can see the

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left ovary that's got a cyst in it.

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And as we scroll down, we can see something

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that looks like a right ovary here, but

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note the position of that right ovary.

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So it's definitely not lateral or adjacent

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to the external or common iliac vessels,

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but it's definitely more inferior to

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its normal location and closer to the midline.

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It's being drawn in or dragged

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in by some other process here.

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So that position of that ovary is not normal.

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All right.

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So we've noted that abnormal position

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of the right ovary, and then the left

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ovary obviously looks enlarged, and we've

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got some T2 shading here, which on T1

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corresponds to some high signal here.

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And this is a nice case

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as well to show you that.

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candle wax phenomenon that we talked about.

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So look at the outside of this left ovary.

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Look at these little cystic structures

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that are next to the ovary, and some

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of them have some high T1 signal.

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So you would be able to see this on ultrasounds.

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We've got an endometrioma with some little

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cysts around it that are hemorrhagic.

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And that's a really nice example

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of the candle phenomenon.

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Okay.

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And then if we look at the torus uterinus.

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So remember, that's along the posterior wall of

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the uterus and kind of anterior to the rectum.

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We've got this ill-defined area of

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pretty low T2 signal, and there's

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an area of kind of high T2 signal.

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And if we look at the T1-weighted

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images in the same area, we've got

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these little dots of high T1 signal.

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So this is definitely a

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manifestation of endometriosis.

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So this is an implant, an area of fibrosis,

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scarring, and probably repeated bleeding.

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So if you're a breast imager, you would

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call this architectural distortion.

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So this is kind of a similar phenomenon

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where the scarring is causing pulling or

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retraction of the adjacent structures.

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You can see the rectal wall here

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is kind of tethered anteriorly.

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So it's pulling in all the

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adjacent structures, the right

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ovary as well as being pulled in.

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And then if we look at the sagittal images, this

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is kind of nice because when we see the torus

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veneratus thickening, this is the area where

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the abnormality would be on the sagittal images.

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And then look what's happened

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to the anterior rectal wall.

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We've got this low T2 signal,

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submucosal lesion here.

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And.

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Hopefully you can imagine that it

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looks like the cap of a mushroom.

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That's what the mushroom cap sign looks like.

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So if you were to do a barium enema in this

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patient, you would see opacification of

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the rectum, and then you'd see this smooth

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semicircular filling defect because of this

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rectosigmoid involvement by endometriosis.

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So, again along the posterior

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margin of the uterus, notice how

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we've got a linear configuration.

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It's not nice and smooth.

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We've got some thickening, a triangular

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shape there, and that corresponds

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to thickening of the torus uteritis.

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So this patient actually has several

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manifestations of endometriosis

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that we've talked about already.

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And then she's also got an IUD here that

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we can see nicely with some susceptibility

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artifact on the gradient echo images.

Report

Faculty

Zahra Kassam, MD, FRCPC

Associate Professor of Medical Imaging, Division Head of Body Imaging

Western University

Tags

Uterus

Rectal/Anal

Pelvic Wall and Floor

Ovaries

Non-infectious Inflammatory

Neoplastic

MRI

Idiopathic

Gynecologic (GYN)

Body

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