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Necrotic Fibroid

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Our next patient is 36 years old and came to the ED

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3 00:00:03,440 --> 00:00:03,800

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with bleeding and pain.

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She gets her ultrasound again.

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We always start with a trans

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abdominal view right here.

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So you can see this is a bit of the uterus right here,

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and then we have all of this shadowing.

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And unlike some of the others we showed

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you earlier, this is dirty shadowing.

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It's not clean anechoic shadowing that you

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would expect to see with calcification.

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So we're suggesting that maybe there's

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going to be air in this particular location.

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And again, this is a transabdominal,

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so you always want to think, am

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I actually looking at bowel here?

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However, this did look like it's

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probably going to be uterus.

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Few more images here.

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Again, this is a very uterine type shape.

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This is the fundus right here, and lots of

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dirty shadowing coming centrally from within it.

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Imaging of the adnexa didn't really

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contribute in this particular case,

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but we do have an enlarged uterus.

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13.

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5 centimeters is bigger than expected.

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And then we skip to our transvaginal,

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where we see some free fluid in the pelvis.

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And again, cervix looks okay.

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Lower uterine segment starts to look okay, and

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then we see all these echogenic foci, and again

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with dirty shadowing posteriorly behind it.

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And it's going to obscure everything

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behind as well, so this is, of course,

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going to be a limited ultrasound.

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At this point, we'll skip

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to some of the cine clips.

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We'll show you here, this is the transabdominal

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sagittal view, and you can maybe see

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a little bit of endometrium out here.

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On the side.

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And as we get more centrally,

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echogenic foci, dirty shadowing,

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can't see much of anything behind it.

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Going back to transvaginal.

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Let's take another look at that.

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See if we can figure out a little

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bit more of what's going on here.

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So whenever you start to see

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gas in the endometrium, which I

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feel like we can confidently say

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that's where this gas is located.

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The first thing I tend to

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think of is endometritis.

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And when you're thinking endometritis, that

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is in a very specific clinical situation.

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So you're going to be recently

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postpartum or post a surgical procedure.

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And so you need to have that history

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in order to diagnose that via imaging.

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They also tend to be pretty toxic.

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They're going to be pretty sick, with high fevers,

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white count, just looking toxic in general.

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And so this patient wasn't in this case.

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So then we kind of had to think

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back and see what's going on here.

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What could this possibly be?

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And I think looking at this

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transverse uterus, syn a clip.

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This is the one that helped us figure

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out the best what's going on here.

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So again, with all the air, it's very easy

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to just get distracted and only think of

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that air and just think, endometritis.

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Endometritis.

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Endometritis.

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I need to call somebody.

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This is important.

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This patient is really sick.

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There's a lot of gas.

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And here I would argue yes,

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that's what I'm still thinking.

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But if you look closer at this and kind of

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take a step back, take your pulse, breathe,

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and you come to the fundal portion of it.

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This is an antidependent air right here.

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It's kind of centrally within the

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canal, and there's just more structure

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going on anteriorly up here.

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We'll go back to that sagittal image right here.

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Air here is very antidependent; air wants to

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float, basically, but over here it's not.

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And that doesn't make sense because if this

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is endometritis, air in the endometrium,

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it should fill the entire cavity, the

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most antidependent portions, and it's not.

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So when you have a case like this, you need

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to again, step back and think about it.

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What else could this be?

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This person wasn't toxic.

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They weren't sick.

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They didn't have a fever or a high white count.

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They were just bleeding and in pain.

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And so it turns out she did

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have a history of a fibroid.

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And so when fibroids get necrotic,

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they can have gas internally.

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It does not mean that they're infected.

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In fact, it's very unusual for them to get

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infected, but when they become necrotic,

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they can have gas internally within them.

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And so this was most likely going

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to be an intracavitary fibroid that

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was necrotizing and had air within it.

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We don't have follow-up at

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our system to prove this.

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She did not end up getting a CT scan, which

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would have been really neat to correlate

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with, but she did go to surgery shortly

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after, which proved that this was a necrotic

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intracavitary fibroid that was causing this.

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So again, endometritis is your first

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thought for this, but if it doesn't fit the

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clinical picture, step back, think about a

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necrotic fibroid as an alternative etiology.

Report

Faculty

Kathryn McGillen, MD

Assistant Professor of Radiology, Medical Director of Ultrasound

Penn State University Milton S Hershey Medical Center

Tags

Vascular

Uterus

Ultrasound

Non-infectious Inflammatory

Neoplastic

Idiopathic

Gynecologic (GYN)

Body

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