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Fig. 18. (A) Hydrosalpinx. Lengthwise, transvaginal view of a dilated, fluid-filled fallopian tube demonstrating residual endosalpingeal folds (arrows). (B) Cross section of the same tube shows the beads on a string sign.
Patients who have severe PID can develop a reactive ileus (Fig. 20), which can be visualized during sonographic evaluation of the pelvis. Perihepatitis associated with PID is known as Fitz-Hugh-Curtis Syndrome, which occurs in 3% to 10% of patients who have PID [22]. The acute right upper quadrant pain often overshadows the pelvic pain because of acute salpingitis. Inflammatory exudates in the pouch of Douglas spread along the peritoneal surface to the anterior surface of the liver by means of the paracolic gutter (Fig. 21). Often alternative diagnoses such as cholecystitis are considered first, and imaging of the right upper quadrant may be requested. Shoenfeld and colleagues [23] found thickening of the right anterior extrarenal fascia
on ultrasound in nine patients. Scattered cases of Fitz-Hugh-Curtis syndrome on CT have demonstrated increased enhancement of the peritoneal surface of the anterior aspect of the liver, gallbladder wall thickening, and a transient hepatic attenuation difference [24,25]. Though the combination of sonographic and clinical findings is often quite specific for PID, there are several other common diagnoses in the differential diagnosis. The most common alternative diagnoses with findings which simulate PID by the presence of an indistinct uterus and complex pelvic fluid, are ruptured hemorrhagic cyst and endometrioma. Perforated appendicitis and ruptured tubo-ovarian abscess may present with indistinguishable findings of peritonitis and intra-abdominal abscesses. Other tubular structures in the pelvis which bear a resemblance to dilated fallopian tubes but should be distinguishable from them include
Fig. 19. Sagittal image of the right adnexa demonstrating loculated fluid with thin septations, surrounding the right ovary compatible with a peritoneal inclusion cyst. The patient has a history of pelvic inflammatory disease.
Fig. 20. Transabdominal image of the right pelvis in a patient with pelvic inflammatory disease demonstrates dilated loops of small bowel without peristalsis, compatible with a reactive ileus.
a hydrosalpinx, it probably signifies an incompletely treated infection.
Related findings and differential diagnosis