Communicating septate uterus with double cervix: a rare malformation.

The class of uterine malformations known as communicating uteri is characterized by two separate uterocervical cavities connected by an isthmic communication. Nine types have been described. We report the second proven case of a septate communicating uterus with double cervix. Investigation of secondary infertility in a woman with a history of second-trimester spontaneous abortion revealed two cervices on a speculum examination. A work-up for uterine anomaly began with endovaginal sonography, which demonstrated a normal fundal contour. A septum symmetrically dividing the endometrial cavity and two cervical canals were seen. The separated endometrial echoes converged at the isthmus, indicating a communicating uterus. Hysterosalpingography confirmed the diagnosis; injection of each cervix resulted in opacification of both hemicavities via the isthmic defect. Laparoscopy confirmed the normal fundal contour. It is believed that the etiology of this malformation involves failure of fusion of the distal müllerian ducts and arrested septal resorption above the isthmus.

Ovarian vein thrombosis with atypical presentation: role of sonography and duplex Doppler.

Ovarian vein thrombosis was diagnosed in two patients, one postoperatively and one postpartum, with mild, atypical presentations, using sonography and duplex Doppler. Demonstration of the dilated ovarian vein with internal thrombus, without demonstrable flow by Doppler, was diagnostic. We propose that sonography with duplex Doppler be the initial screening examination in at-risk patients with typical or atypical presentations.

Diagnostic imaging in puerperal febrile morbidity.

This retrospective study was conducted to assess the value of imaging in patients with refractory puerperal febrile morbidity. During a 36-month period, 31 patients were referred for ultrasound and/or computed tomography or magnetic resonance imaging because of postpartum fever unresponsive to broad-spectrum antibiotic therapy of at least 72 hours' duration. Hematomas were identified in 11 women. Abscesses were diagnosed in seven patients, ovarian venous thrombosis in two, vesicouterine fistula in one, small-bowel obstruction in one, and a subcutaneous seroma in one. Twenty-one women had endomyometritis, 13 of whom also had other extrauterine abnormalities (abscess in six, hematoma in four, and ovarian venous thrombosis, vesicouterine fistula, and small-bowel obstruction in one each). Retained placental tissue was found in two women with endomyometritis. Only two subjects had negative imaging studies. In most patients, imaging led to definitive diagnosis and specific therapeutic measures resulting in resolution of the febrile morbidity. Our experience suggests that these imaging techniques may be helpful in evaluating puerperal fever.

Staging of ureteral transitional cell carcinoma by CT and MRI.

Intravenous urography and retrograde pyelography are the primary radiologic studies for detecting ureteral carcinoma but give limited information regarding stage of disease. Computed tomography (CT) and magnetic resonance imaging (MRI) delineate the extent of ureteral carcinomas with a high degree of accuracy by depicting the periureteral fat and presence or absence of lymphadenopathy. In selected cases, CT and MRI are valuable for assessing the presence or absence of tumor in a ureteral stump and for the differential diagnosis of ureteral obstruction. Five cases of ureteral carcinoma and 2 cases of stump carcinoma are presented with preoperative CT and/or MRI evaluation and staging.

Communicating uteri: review and classification with introduction of two previously unreported types.

Four cases of communicating uteri, representing two previously unreported types, are presented. Forty-nine reported cases of communicating uteri are reviewed and reclassified into nine types. Clinical and embryologic aspects are discussed.

Controlled ovarian hyperstimulation and transvaginal intratubal insemination as an alternative to gamete intrafallopian transfer.

OBJECTIVE: To evaluate the efficacy of controlled ovarian hyperstimulation (COH) followed by intratubal insemination in the treatment of infertility. DESIGN: Retrospective analysis of 179 intratubal insemination trials in 78 women over a 48-month period. SETTING: Reproductive endocrinology practice. PATIENTS: Seventy-eight women, 26 to 44 years old (34 +/- 4.3 years; mean +/- SD), classified into subgroups according to diagnosis and age (< 40 or > or = 40 years). INTERVENTIONS: Patients underwent COH and intratubal insemination. MAIN OUTCOME MEASURES: The rates of pregnancy, delivery, spontaneous abortion, ectopic and multiple gestation, and complications were studied and analyzed statistically. RESULTS: Overall, there were 36 pregnancies (20.1% of 179 trials), 29 deliveries (16.2%), 5 of 36 first trimester abortions (13.9%), 2 of 36 ectopic pregnancies (5.6%), and 4 twin gestations. There were no serious complications. In 43 women < 40 years without male factor the first trial resulted in 15 pregnancies (34.9%); in 27 women < 40 years with male factor the first trial resulted in 4 pregnancies (14.8%). Male factor reduced significantly the probability of conception. In 19 women < 40 years of age with either ovarian dysfunction or infertility of unknown cause, the first trial resulted in 9 pregnancies (47.4%), which was significantly better than the 10 pregnancies achieved in the first trial in the remaining 51 women < 40 years of age. Peak serum E2 levels and number of mature follicles had a significant effect on pregnancy rates. CONCLUSIONS: Intratubal insemination yielded pregnancy rates comparable to those published for GIFT at reduced cost and with fewer complications.

Comparison of unenhanced and contrast-enhanced spiral CT for assessing interval change in patients with colorectal liver metastases.

RATIONALE AND OBJECTIVES: The purpose of this study was to determine whether the interval change in hepatic colorectal metastases as assessed with serial computed tomographic (CT) scans without contrast material enhancement differs from that as assessed using serial, portal dominant phase, contrast-enhanced CT scans. MATERIALS AND METHODS: Unenhanced and contrast-enhanced abdominal CT scans were obtained in 28 patients. Three radiologists separately reviewed serial unenhanced and contrast-enhanced studies to assess the interval change in liver metastases. These radiologists recorded total number of lesions, bidimensional measurements of the largest lesions (as many as three), and overall impressions regarding the interval change (none, worse, or better). RESULTS: Among the 84 judgments (28 patients x 3 radiologists), comparisons of unenhanced and contrast-enhanced CT studies were concordant in 60 assessments (71%). Nineteen (23%) showed mild disagreement. Of these, contrast-enhanced CT studies demonstrated disease stability when unenhanced CT studies demonstrated otherwise in 11 judgments, whereas unenhanced CT studies demonstrated stability when contrast-enhanced CT studies demonstrated otherwise in eight assessments. Furthermore, of the five marked disagreements, two resulted from a conclusion of interval improvement on unenhanced CT studies and a conclusion of interval worsening on contrast-enhanced CT studies, whereas three demonstrated the opposite. Neither set of serial CT studies systematically resulted in under- or overestimation of disease progression (McNemar Q test, P < .25). CONCLUSION: The authors found no consistent pattern to demonstrate that serial unenhanced or contrast-enhanced CT studies resulted in over- or underestimation of disease progression.

Clinical impact of sonographically guided biopsy of salivary gland masses and surrounding lymph nodes.

Although fine-needle aspiration biopsy of salivary gland masses has been reported in the otolaryngology literature, the use of sonography to guide the biopsy of nonpalpable masses and masses seen on other cross-sectional imaging studies has not been described. Our goal was to evaluate sonographically guided biopsy of masses and lymph nodes related to the salivary glands. We analyzed the records of 18 patients who had undergone fine-needle aspiration biopsy of a salivary gland mass or lymph node with a 25-, 22-, or 20-gauge needle. A definitive cytologic diagnosis was made for 13 of the 18 patients (72%); cytology was suggestive but not definitive in three patients (17%) and insufficient in two (11%). Definitive diagnoses were made in three cases of reactive lymph node, in two cases each of lymph node metastasis and Warthin's tumor, and in one case each of pleomorphic adenoma, adenoid-cystic carcinoma, schwannoma-neurofibroma, parotid metastasis, parotid lymphoma, and Sjögren's-related lymphoid-epithelial lesion. Sonographically guided biopsy allows for confident needle placement in masses seen on computed tomography and magnetic resonance imaging. Sonography can usually distinguish a perisalivary lymph node from true intrasalivary masses, and it can help the surgeon avoid the pitfall of a nondiagnostic aspiration of the cystic component of masses. We conclude that sonographically guided biopsy of salivary gland masses can provide a tissue diagnosis that can have a direct impact on clinical decision making.

Esophageal strictures: findings on barium radiographs.

An esophageal stricture is a narrowing of the lumen due to inflammation or tumor. Lack of distensibility is characteristic of stricture, which may be diffuse or localized and which may have abrupt or tapered margins. The purpose of this essay is to illustrate the imaging features of various types of strictures, focusing on their value in differential diagnosis.

"Drooping shoulder"--nontraumatic causes of glenohumeral subluxation.

Nontraumatic glenohumeral subluxation can occur in patients with hemiplegia or brachial plexus involvement by tumor. Two cases of inferior subluxation of the humeral head are presented and nontraumatic etiologies of the "drooping shoulder" are discussed.

Imaging of uterine leiomyomas.

Advances in the medical and surgical treatment of uterine leiomyomas have stimulated interest in the imaging of these common tumors. The purpose of this essay is to illustrate the appearance of leiomyomas on images obtained with various techniques. The advantages of each technique in particular clinical circumstances are discussed.

Hysterosalpingography before and after myomectomy: clinical value and imaging findings.

OBJECTIVE: Myomectomy is being performed increasingly for the treatment of menorrhagia and infertility. The purpose of this study was to describe the findings at hysterosalpingography before and after myomectomy and to correlate the findings with the operative technique and observations at surgery. This study also examined the value of hysterosalpingography in planning surgery, as well as in detecting postoperative complications and residual fibroids. MATERIALS AND METHODS: The study group comprised 32 patients who were consecutively referred for hysterosalpingography after myomectomy. The indications for myomectomy were infertility in all cases, associated with menorrhagia in 20, pelvic pain in 15, and urinary frequency in eight. Eighteen of the 32 patients also had hysterosalpingography before surgery. The hysterosalpingographic findings were reviewed without knowledge of the clinical findings and then correlated with surgical and pathologic findings. RESULTS: Preoperative hysterosalpingograms showed enlargement and/or distortion of the uterine cavity in 13 of 14 patients who had submucous fibroids or mural fibroids with a submucous component (mural/submucous fibroid). Cornual asymmetry was seen in seven of 18 patients, the result of an adjacent fibroid deforming one bilaterally in another two. In all four patients, tubal patency was shown after myomectomy. Intracavitary filling defects consistent with submucous or mural/submucous fibroids were found in 12 of 18 patients. After myomectomy, these defects resolved in eight cases; in the remaining four, persistent filling defects suggested residual submucous enlargement of the uterine cavity in only two of 32 patients; in both, residual mural and/or submucous fibroids were shown on sonography after surgery. Major distortion of the cavity after surgery was found in four patients; it was caused by filling defects consistent with residual submucous fibroids in two and by major synechiae in two. Diverticula at the site of resection of submucous fibroids were found in six patients. Major synechiae were found in two patients, resulting in unilateral or bilateral tubal occlusion. CONCLUSION: Hysterosalpingography before myomectomy can assist the surgeon in planning the surgical approach by showing the presence, size, and location of submucous fibroids and concomitant tubal disease. Hysterosalpingography after myomectomy shows residual fibroids and complications of surgery, such as synechiae and diverticula, that may affect further treatment.

CT assessment of abdominal hemorrhage in coagulopathic patients: impact on clinical management.

BACKGROUND: To assess how computed tomography (CT) affected clinical management in coagulopathic patients with suspected spontaneous abdominal hemorrhage. METHODS: Fifty-four patients with coagulopathy underwent CT for possible abdominal hemorrhage. Medical records were reviewed retrospectively for pre-CT management strategy, degree of clinical suspicion for abdominal hemorrhage, CT findings, and post-CT management strategy. RESULTS: Abdominopelvic CT demonstrated hemorrhage in 31/54 (57%) of patients; 20/54 (37%) of patients had retroperitoneal hemorrhage, 2/54 (4%) had hemoperitoneum, and 9/54 (17%) had hemorrhage confined to the thigh, groin, and/or abdominal wall. CT directly affected clinical management in 28/54 (54%) cases; 17/31 (55%) CT scans that were positive for hemorrhage had a clinical impact versus 11/23 (48%) negative CT scans. This difference was not statistically significant (p = 0.61). CT scans with a higher pretest suspicion for abdominal hemorrhage were more likely to have hemorrhage detected (p = 0.0046) but not more likely to have a clinical impact (p = 0.73). CONCLUSIONS: CT to assess for abdominal hemorrhage had a direct impact on clinical management in about one-half of coagulopathic patients. Positive and negative CT studies were equally likely to affect management.

CT findings in venous intravasation complicating diverticulitis.

A case of venous intravasation mimicking coloureteral fistula in a patient with sigmoid diverticulitis is reported. Venous intravasation is a rare but serious complication of barium examination of the colon.

Value of sonohysterography in the diagnosis and management of abnormal uterine bleeding.

PURPOSE: To assess the value of sonohysterography in the diagnosis and management of abnormal uterine bleeding. MATERIALS AND METHODS: Sonohysterography was performed in 28 women (aged 29-55 years) in whom transvaginal sonography (TVS) suggested an abnormal endometrial echo (n = 14) or fibroids (n = 14). Its effect on diagnosis and treatment was studied. RESULTS: In the patients with an abnormal endometrial echo, sonohysterography depicted endometrial polyps (n = 9), intracavitary fibroids (n = 3), placental polyp (n = 1), and a normal cavity (n = 1). Hysteroscopic resection resolved the bleeding in 11 of 14 patients; surgery was obviated in one. In the group with fibroids, sonohysterography depicted small submucous fibroids amenable to hysteroscopic myomectomy (n = 5), a small mural fibroid with a normal cavity, which obviated surgical intervention (n = 4), and endometrial polyps, which altered the treatment plan (n = 1). Sonohysterography suggested the need for an abdominal myomectomy (n = 4) and alerted the surgeon to explore the uterine cavity in three patients. CONCLUSION: By helping elucidate the cause of bleeding, sonohysterography assisted in determining the therapeutic approach and often reduced the level of surgical intervention or obviated it altogether.