ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update.

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (ß-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative ß-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive ß-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative ß-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

I saw the "kissing ovaries" sign: Too close for comfort.

The Kissing ovaries sign is a radiological sign seen in women with deep pelvic endometriosis. It refers to abutment of the ovaries within the cul-de-sac. The term kissing ovaries was first described by Ghezzi et al. (2005) and has been since used widely. When seen on imaging it indicates moderate to severe endometriosis with the ovaries tethered within abnormal pelvic soft tissue, which may warrant surgical management.

MRI defecography revisited. At-rest pelvic floor measurements with and without rectal gel. Is there a difference?

PURPOSE: The authors sought to test if there was a difference in key pelvic floor measurements obtained during MR defecography at-rest, i.e., H-line, M-line and anorectal angle (ARA), before and after rectal gel administration. The authors also sought to determine if any observed differences would affect the interpretation of the defecography studies. METHODS: Institutional Review Board approval was obtained. An abdominal fellow retrospectively reviewed the images of all patients who underwent MRI defecography at our institution from January 2018 through June 2021. The H-line, M-line and ARA values were remeasured on T2-weighted sagittal images, with and without rectal gel for each patient. RESULTS: One hundred and eleven (111) studies were included in the analysis. 18% (N = 20) of patients satisfied the criterion for pelvic floor widening before gel administration based on H-line measurement. This increased to 27% (N = 30) after rectal gel (p = 0.08). 14.4% (N = 16) met the M-line measurement criterion for pelvic floor descent before gel administration. This increased to 38.7% after rectal gel (N = 43) (p < 0.001). 67.6% (N = 75) demonstrated an abnormal ARA prior to administration of rectal gel. This decreased to 58.6% (N = 65) after rectal gel administration (p = 0.07). The overall reporting discrepancies incurred by the presence or absence of rectal gel were 16.2%, 29.7% and 23.4% for H-line, M-line and ARA, respectively. CONCLUSION: The instillation of gel during MR defecography can cause significant changes to the observed pelvic floor measurements at-rest. This in turn can influence the interpretation of defecography studies.

Interobserver Agreement Between Primary Sonographers and Secondary Overreaders for Screening and Surveillance Liver Ultrasounds Using Ultrasound Liver Imaging Reporting and Data System.

ABSTRACT: The authors aim to identify if primary sonographers and secondary reviewers, both radiologists and sonographers, are likely to assign the same Ultrasound Liver Imaging Reporting and Data System (US LI-RADS) scores for liver surveillance ultrasounds. Institutional review board approval was obtained. Sonographers were familiarized with US LI-RADS via radiologist-led lectures. Three sonographers prospectively scored 170 screening examinations using US LI-RADS recommendations. Scans were retrospectively rescored by a fourth sonographer and a radiologist, both of whom were blinded to the original scores. Results were analyzed with weighted and nonweighted Cohen kappa statistical analysis methods. There was near-perfect agreement between primary and secondary sonographers and primary sonographer and radiologist (kappa of 0.87 and 0.92, respectively) for US LI-RADS category (cat) scores. However, only substantial and moderate agreements were noted for visualization (vis) scores between primary and secondary sonographers and primary sonographer and radiologist (weighted kappa of 0.73 and 0.48, respectively). There was vis score disagreement between the primary sonographer and radiologist in 60 (35.3%) cases. In 35 (20%) cases, the radiologist assigned a lower/more conservative vis score. There was vis score disagreement between the primary and secondary reviewing sonographers in 30 (17.6%) cases. In 12 (7%) cases, the secondary sonographer assigned a more conservative vis score. Although a good degree of concordance was noted between the groups, radiologists will need to generate their own US LI-RADS scoring to accurately reflect their impression and appropriately steer management.

Ultrasound Liver Imaging Reporting and Data System (US LI-RADS): An Overview with Technical and Practical Applications.

The Ultrasound Liver Imaging Reporting and Data System (US LI-RADS), introduced in 2017 by the American College of Radiology, standardizes the technique, interpretation, and reporting of screening and surveillance ultrasounds intended to detect hepatocellular carcinoma in high-risk patients. These include patients with cirrhosis of any cause as well as subsets of patients with chronic hepatitis B viral infection. The US LI-RADS scheme is composed of an ultrasound category and a visualization score: ultrasound categories define the exam as negative, subthreshold, or positive and direct next steps in management; visualization scores denote the expected sensitivity of the exam, based on adequacy of liver visualization with ultrasound. Since its introduction, multiple institutions across the United States have implemented US LI-RADS. This review includes a background of hepatocellular carcinoma and US LI-RADS, definition of screening/surveillance population, recommendations and tips for technique, interpretation, and reporting, and preliminary outcomes analysis.

Review of MRI imaging for placenta accreta spectrum: Pathophysiologic insights, imaging signs, and recent developments.

Placenta Accreta Spectrum (PAS) refers to the range of abnormally adhesive and penetrative placental tissue at a uterine scar. PAS is divided into accreta, increta, and percreta based on degree of myometrial invasion. Its incidence has increased, and PAS is now the leading indication for emergency peripartum hysterectomy in the setting of catastrophic hemorrhage from a non-separating placenta. The recent release of the International Federation of Gynecology and Obstetrics (FIGO) guidelines in 2018 coupled with the joint consensus statement from the Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) in 2020 reflect decades worth of diagnostic and therapeutic advances in this field. Although the increasing role of MRI in PAS diagnosis is evident, the literature on PAS reveals several disparate but conceptually overlapping MRI signs. Identifying and differentiating between placenta increta and percreta on imaging may be quite challenging even with MRI and sometimes even on final pathology. In this review, we aim to (i) provide a clarified understanding of PAS pathophysiology, (ii) comprehensively review and classify MRI signs based on pathophysiologic underpinnings, (iii) highlight shortcomings in the current PAS literature; and (iv) highlight best practice guidelines for imaging diagnosis of PAS.

Anterior urethral strictures and retrograde urethrography: An update for radiologists.

Urethral strictures are a relatively common affliction of men with the anterior urethra being most frequently affected. Anterior urethral strictures (AUS) typically present with obstructive voiding symptoms and appropriate management is often based on findings at cystourethroscopy and retrograde urethrography (RUG). In particular, determining the number, length, severity and location of urethral strictures is of pivotal importance. The accurate reporting of findings at RUG is dependent on a thorough knowledge of the urethral anatomy as well as recognizing periurethral structures that may opacify during the procedure. Obtaining a diagnostic, high-quality RUG study requires adherence to proper fluoroscopic technique as well as recognizing when to adjust or modify the technique to address pitfalls that may be encountered during the procedure. AUS may be treated by a variety of procedures including urinary diversion, transurethral procedures such as urethral dilation and internal urethrotomy and open surgical repair techniques termed urethroplasty. Some authors have recommended urethroplasty as first-line treatment given the high rate of stricture recurrence with other treatment options. Buccal mucosal grafts are a mainstay of modern urethroplasty. Familiarity with the commonly performed urethroplasty procedures allows radiologists to accurately assess the post-operative urethra thus guiding the management of these patients.

Ultrasound Evaluation in Patients at Risk for Hepatocellular Carcinoma.

In the context of chronic liver disease (CLD), sonographic features of hepatic steatosis, cirrhosis, and portal hypertension are discussed and examples are provided. The impact of CLD and hepatocellular carcinoma (HCC) is introduced, providing the rationale for a robust HCC screening and surveillance program for at-risk patients. The American College of Radiology Liver Imaging Reporting and Data System algorithms for screening and surveillance by ultrasound and for the definitive diagnosis of HCC by contrast-enhanced ultrasound are explained, with imaging examples provided. Contrast-enhanced ultrasound technique, limitations, and pitfalls also are introduced.

Endometriosis revisited: an imaging review of the usual and unusual manifestations with pathological correlation.

The manifestations of endometriosis commonly present a diagnostic challenge to the gynecologist and radiologist. Familiarity with its varied presentations may allow for a more accurate diagnosis. The goal of this review is to the present the imaging spectrum of endometriosis, less common sites of involvement as well as the potential rare complications. Relevant surgical and histopathological correlation is also provided. In addition to clinical evaluation and sonography, MRI is a highly accurate imaging modality in the diagnosis of endometriosis. It possesses a distinctive advantage over other modalities in that it allows a complete survey of the pelvic compartments. The potentially devastating effects of endometriosis include pelvic pain and even infertility. Since standard treatment is surgical, the radiologist needs to be familiar with the various manifestations in order to aid diagnosis for appropriate management.

Radiologist and Sonographer Interpretation Discrepancies for Biliary Sonographic Findings: Our Experience.

PURPOSE: The aim was to determine the discrepancy rate between the preliminary interpretation by sonographers and the final radiology interpretation for biliary sonographic findings. MATERIALS AND METHODS: Institutional review board approval was obtained. Four hundred consecutive right upper quadrant sonographer performed ultrasounds were reviewed retrospectively. Sonographers' worksheets were compared with the final radiology report. For the purposes of this project, only the biliary findings were compared and reviewed. Discrepant findings were reviewed by 5 ultrasound experts, and a majority vote sought to determine truth, sonographer worksheet findings, or radiologist report. The clinical impact of the discrepant findings was also evaluated. RESULTS: Of the 400 scans, there were 338 agreements and 62 discrepancies. The overall discrepancy rate was 15.5%. The most frequently contested discrepancy was the presence or absence of pericholecystic fluid n = 21. Sonographers (S) were deemed correct 8 times and radiologists (R) 13 times, denoted 8/13 (S/R). The overall split was 30/32 (S/R) with radiologists deemed correct 52% of the time and sonographers 48% of the time. Using a 1-sample proportion χ test with Yates' continuity correction, there were no statistically significant discrepancies between the 2 groups. CONCLUSIONS: We observed an interpretation discrepancy rate of 15.5% with radiologists deemed correct slightly more frequently, although this did not meet statistical significance. Clinically impactful discrepant findings (6.5% of all discrepancies) were all correctly called by the radiologists. Both groups bring tremendous value to the ultrasound arena, and continued collaboration should be encouraged. PURPOSE: The aim of this study was to determine the discrepancy rate that exists between the preliminary interpretation by sonographers and the subsequent final radiology interpretation for biliary sonographic findings.

Case 213: primary splenic angiosarcoma.

History A 75-year-old woman with a medical history of gastroesophageal reflux disease and type II diabetes presented to the hospital with a 3-month history of gradually worsening headaches, vague upper abdominal pain, and lower back pain. The patient denied fevers, night sweats, contact with sick individuals, occupational exposure to infection, bleeding, immunodeficiency, intravenous drug use, alcohol or tobacco abuse, history of malignancy, family history of genetic disorders, and international travel. Physical examination revealed a skin-colored mass protruding from the right side of her forehead, but there were no other notable abnormalities. Her diabetes was managed with diet, and the only prescription medication she was taking was esomeprazole. She was not taking anticoagulants. Initial laboratory work-up revealed anemia and profound thrombocytopenia (hemoglobin level, 9.4 g/dL; platelet count, 16 × 10(9)/L); these were refractory to aggressive treatment, including plasmapheresis, immunosuppression with prednisolone, and numerous transfusions. Contrast material-enhanced magnetic resonance (MR) imaging of the head was performed at admission to further evaluate the patient's headache and the mass on the patient's forehead. Ultrasonography (US) of the abdomen was performed to evaluate the cause of abdominal pain. The discovery of liver lesions at US led us to perform contrast-enhanced computed tomography (CT) of the chest, abdomen, and pelvis. Contrast-enhanced MR imaging of the abdomen was performed to narrow the diagnostic considerations for the lesions identified at CT. Bone marrow biopsy revealed no evidence of infectious or neoplastic processes. Endoscopy and colonoscopy were performed; however, they revealed no abnormalities. Further laboratory work-up included extensive testing for parasites, fungi, bacteria, and viruses, including the human immunodeficiency virus (HIV). All of the results were negative. On the 17th day of admission, the patient became acutely unresponsive, her condition deteriorated rapidly, and she died. Unenhanced head CT was performed at the time of the patient's acute decompensation.