 Hello everybody. I am Dr Avni Skandhan, lead consultant and head of radiology and the quality chief at ASTEM M. Scotical. I am pre-passionate about academics and teaching and I am currently the faculty of Indian radiologist. Pelvic inflammatory disease is one of the commonest causes of acute pelvic pain and ultrasound happens to be the first modality that we use for investigating this cause of pain. Unfortunately, all the people do not know the findings or the entire spectrum of findings that we can come across in pelvic inflammatory disease due to which most often this disease entity gets overlooked and we end up diagnosing the disease in the latest stages. So here I am describing the early and the late findings and hoping that we will actively look for and be able to pick up this disease entity in the earlier stages. Thank you. Ultrasound in pelvic inflammatory disease. Pelvic inflammatory disease or the PID is inflammation of the female upper genital tract and the supporting structures. It primarily begins as an infection which essence upwards from the vagina, goes to the cervix causing cervicitis, goes upwards into the individual canal and its lining resulting in endometritis, extends into the tube and involves the tubes causing salpinchitis to the ovaries leading to uphoritis where it involves the tubo ovarian complex. It forms tubo ovarian abscess and when it extends into the peritoneal cavity or the peritoneal lining, it leads to peritoneitis. So we are primarily talking about the ultrasound imaging of this. So what do we see in the early stages of PID? We can see it as a cervicitis. When we are seeing this in inflammation of the uterine cervix, we find the cervix is bulky, hypoechoic and hyperemic and many times you might not be able to differentiate the lining or there might be some paramaterial fact inflammation that is seen. There can be associated free fluid in the POD or fluid within the endoservical canal. This is a common finding that we come across. Sometimes it might be very subtle when you see this haziness in the endoservical lining. It might extend into the endometrial canal. When the patient might be in a subclinical stage, it is difficult to diagnose this because you might just see some fluid collection in the endometrial cavity. There might be some contents or septations but you know for sure that it is an abscess formation or a collection when you see there is air pockets within the endometrial canal. Intraendometrial fluid with endometrial hyperplasia, endometrial haziness and paramaterial inflammation is a spectrum of findings that you see in endometritis. You might see the uterine borders to be indistinct and this would be difficult to pick if it was in isolated finding when it is associated with an endometrial canal collection. It is easier for us to pinpoint the diagnosis. When it extends into the tube, the tube tends to become thickened and the walls are hyperemic. You might see some fluid collection within the tube when it becomes easier to diagnose. So this is the finding that we see in salpingitis, predominantly the tubal wall thickening and hyperemia. There might be again some associated fluid that we see in the adjacent adnexa or the POD. When it extends into the ovary or involves the ovary, we tend to see a bulky hypoechoic and a hyperemic ovary and it tends to show a polycystic ovarian morphology because of the ovarian edema and the stroma edema causes the small follicles to be pushed to the periphery, giving the classical polycystic like appearance. But the thing to be remembered here is that the ovarian stroma per se will be hypoechoic and hyperemic. You might also find adjacent fluid collection in the periovarian region. Peritonitis is ideally a finding that we see in the CT. So on an ultrasound, the indirect findings or rather if you see this fluid with contents in the peritoneal cavity, you know that you might be looking at a peritonitis. So what do we see in the late stages of PID? In the late stages of PID, when we see that the infection has progressed, it might cause some blockage in the tubes and because of which there is some accumulation of the pus within the tubes, causing distention of the tubes and resulting in the formation of a pyosalpenx. Here the tube is thickened, hyperemic and you will see that there's debris which might change position, which might cause fluid-fluid layering and this is the classical appearance that we see of pyosalpenx. It might be sometimes difficult to differentiate it from bubble because the tubes might get extensively dilated. If so, a cogwheel sign, which is the thickened and eddy matters endosalping gel fold is considered relatively specific or rather very specific for pyosalpenx. So cogwheel sign is something that we should look for when we are looking at a massively dilated tube. When we are following up these cases, the pyosalpenx, what tends to happen is the pus tends to undergo proteolysis and the pus gets converted into a thin simple fluid. So the pyosalpenx tends to start looking like a hydrosalpenx as it is resolving. Next we have the hydrosalpenx, which can be the first presentation that we come across, where we have the tube which is dilated, fluid filled with clear contents. You will see the incomplete septations and as the tube gets dilated, it tends to fold over itself, but it tends to continue maintaining the C or the S shape morphology. That is very classical of the hydrosalpenx. So when the hydrosalpenx or the tubes are massively dilated, we might mistake it for a multi-lockless cyst, but we have to look out for these findings such as the incomplete septation, the cogwheel sign or the fact that it will continue to maintain the C or S shape morphology to some extent, even if it becomes enlarged. So this hydrosalpenx can be a primary finding or as a resultant finding in a follow-up case of a pyosalpenx. When the infection progresses, it can lead to a blockage in the tubo-variant drainage system and the entire tubo-variant complex gets involved and inflamed. It results in the formation of a mass-like thing which is appearing heterogeneous. It can be hyper-echoic or hypoechoic. Either ways, you will not be able to differentiate the tubes and the ovaries separately. That is the classical appearance of a tubo-variant lesion or a tubo-variant mass or collection. The entire thing will have either an abscess formation or would appear an inflammatory mass on its own. Either ways, you will not be able to tell the tubes and the ovaries apart. And this is an acute emergency because a tubo-variant abscess needs to be drained emergently. It does not treat it with an antibiotic course like pyosalpenx. Pyometra is another complication that we see when there is a blockage in the drainage system of the uterine cavity. What happens is that there is an abscess or pus collection that starts to occur within the endometrial canal which is the pus filling in the uterine cavity. So this is the pyometra and when we see the debris, we can understand that this is pyometra. You might see fluid fluid level and especially if you see air pockets undoubtedly you know you're dealing with pyometra. And we will also see associated hyperemia in the endometrial lining or the myometrium and the parametral fat also. So what are the complications of PID that we can come across? PID is the commonest cause of tubal blockage and the commonest cause of infertility. But this is something that we cannot pick up on ultrasound. Peritonitis we have already discussed. Peritoneal adhesions due to recurrent PID, the peritoneal adhesions can occur. Fitzhugg Curtis syndrome is a type of perihepatitis which I would be talking further. Ovaline vein thrombophlebitis can occur. Uterine rupture is a devastating complication but it is rare and it can occur. Peritoneal cirrhosis is possibly one of the commoner complications that we come across. So I will talk only about the findings that we can see on ultrasound. Fitzhugg Curtis syndrome is a type of perihepatitis. It is a rare complication of PID. What happens here is the inflammation or the infection from the pelvis tends to ascend along the right paracolic gutter till the capsule, the anterior capsule of the liver. This is primarily a diagnosis of cross-sectional imaging. However, the findings that we can pick up on ultrasound is that this patient would be having inflammation and inflammatory focus in the pelvis with possibly an abscess formation. You will see inflammation in the right paracolic gutter. There can be free fluid with septations predominantly in the right paracolic gutter. And as it ascends into the right upper quadrant, we tend to see because of the inflammation in the perihepatic region, we tend to see gallbladder wall edema. So it is not a diagnosis that you can put forth confidently but when you know that the patient is having pelvic inflammatory disease or when you are seeing that this patient is having an abscess in the pelvis and you are seeing these associated findings in the right upper quadrant, you have to put two plus two together and come to a diagnosis of perihepatitis. Another complication that can be picked up, especially if the patient is thin and the resolution of the machine is good, you might be able to pick up ovarian vein thrombophlebitis. It is predominantly seen on the right side and with a good resolution we might be able to pick up a distended vein with thrombus within. There can be inflammation that we see adjacent, but this is a finding which is primarily or most often we come across in cross-sectional imaging. It is very rare that we see this in the ultrasound. Uterine rupture is a devastating complication and this patient would probably collapse, would be in a hypovolemic shock by the time the patient arrives to you. In this what happens is the pus collection in the uterus, in the uterine cavity has increased to such an amount that it is causing uterine thinning. Because of the pressure in the uterine wall, the uterine myometrium starts undergoing necrosis and sloughing and finally at one point it just gives way. This point that it gives way tends to occur in the fundus of the uterus and so the entire pus from the uterine cavity tends to spill over into the peritoneal cavity resulting in uterine rupture. The patient immediately collapses, goes into hypovolemic shock and what happens badly is that this collection tends to extend into the peri uterine space. A collection occurs there and you tend to get associated peritonitis. So the imaging findings that we would see is you might see biometra, you might be able to appreciate the defect, you will see a peri uterine collection and features of peritonitis. The most common finding that we come across in ultrasound as a complication of PID is a pelvic inclusion cyst. Pelvic inclusion cysts tend to be large cysts which are clear, thin wall, multi-loculated and the characteristic finding in this is that it tends to insinuate between the various pelvic structures. It does not tend to cause any mass effect or displacement of any of the pelvic structures, it just passes through the space that is available for it and most often these patients would have a prior history of PID or endometriosis or pelvic surgeries. So to conclude what are the important findings that we come across? We see in PID the most common thing that we are used to is seeing reports that state there is fluid in the POD query PID but that is a very vague kind of a report because fluid in the POD is also physiological process for a female so a better clarity and looking for other additional findings would also be helpful and would help them reach a diagnosis. So when you can look in ultrasound the findings initially can be very subtle but you can look for other than the presence of fluid you can look for features such as evidence of pelvic fat edema, thickening of the fallopian tubes, a presence of oophritis where there's a bulky ovary, hypoechoic and hyperemic, cervix being bulky, hypoechoic, again hyperemic, paramaterial fat inflammation, endometrial canal fluid collection. These are all the findings that we see in the early stages of PID. As it progresses we come across a finding such as pyosalpins and tuboavirinapsises which are easier to pick because they are more evident findings but it would be always best if we are able to look for the findings in the earlier stages and be able to create it in the earlier stages so we have to be aware of it and look for these findings actively and not wait for the later findings to present. So yes knowledge isn't power but when we apply the knowledge it definitely is power so thank you and hopefully this was helpful for you.