Computed tomography and magnetic resonance imaging in the evaluation of pelvic peritoneal adhesions: What radiologists need to know?

Nitin P Ghonge, Sanchita Dube Ghonge, Nitin P Ghonge, Sanchita Dube Ghonge

Abstract

Pelvic peritoneal adhesions constitute an important cause of concern which affects the life of millions of people worldwide due to complications like abdominal pain, bowel obstruction and infertility along with challenges in surgical exploration. Precise pre-operative diagnosis of the presence and extent of peritoneal adhesions is of great clinical and surgical importance. Diagnostic laparoscopy to detect peritoneal adhesions may itself lead to formation of adhesions. Routine CT and MRI studies are therefore useful non-invasive modalities to achieve this objective. This review article provides a brief background about the causation and patho-physiology of peritoneal adhesions. The article also addresses the range of clinical presentations in these patients, mainly from the gynecologic perspective. This article provides an illustrative review of CT and MRI findings with laparoscopic correlation. A new 'imaging-based grading system' for pre-operative quantification of the burden of peritoneal adhesions is also proposed. Despite practical challenges in accurate pre-operative diagnosis of peritoneal adhesions on imaging, detection of peritoneal adhesions is certainly feasible on routine CT and MRI scans and should be an integral part of image interpretation.

Keywords: Computed tomography; magnetic resonance imaging; pelvic peritoneal adhesions.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1
Figure 1
Flow chart to illustrate the causation and patho-physiology of adhesion formation in the peritoneal cavity
Figure 2
Figure 2
Line diagram to illustrate the types of peritoneal adhesions and their common clinical presentations
Figure 3
Figure 3
Sagittal T2W MR image showing the normal anatomy of the utero-vesical fold (UV-fold, short arrow) and the pouch of Douglas (POD, long arrow) with corresponding laparoscopic images
Figure 4
Figure 4
Sagittal T2W MR and sagittal CT images showing the normal appearance of pro-peritoneal fat line (arrows) with corresponding laparoscopic image and line diagram [RA: Rectus abdominis, UB: Urinary Bladder, UT: Uterus, RE: Rectum]
Figure 5
Figure 5
Sagittal CT image showing the focal obscuration of pro-peritoneal fat line (arrows) with corresponding laparoscopic image, which suggests entero-parietal adhesions
Figure 6
Figure 6
Axial and coronal CT images showing the focal thickening and retraction of bowel wall with corresponding laparoscopic image (arrows), which suggests lateral entero-parietal adhesions
Figure 7
Figure 7
Sagittal CT image with corresponding line diagram showing the stretched adherent uterus (arrows) with increased utero-cervical length. [UB: Urinary Bladder, UT: Uterus, RE: Rectum]. This suggests anterior uterine adhesions
Figure 8
Figure 8
Sagittal T2W MR images showing recto-uterine pouch (Pouch of Douglas) adhesions (arrows). There is blunting of the POD due to these posterior uterine adhesions
Figure 9
Figure 9
Axial CT image showing thick enhancing peritoneal band (arrow) extending between the ovarian cyst and the small bowel (SB) loop with corresponding laparoscopic image [UT: Uterus]. CT and MR images of these deep pelvic adhesions show excellent correlation with laparoscopy
Figure 10
Figure 10
Axial T2W MR image showing bilateral ovarian cysts with shading phenomenon on T2WI (arrows) to suggest endometriomas. These cysts are seen posterior to uterus (UT) and are adherent to each other (‘kissing ovaries’). The corresponding laparoscopic image shows excellent correlation with MRI findings
Figure 11
Figure 11
Coronal CT image (left panel) showing an enhancing peritoneal band (long arrow) causing focal compression over the small bowel loop with mild proximal obstruction. Another patient (right panel) showing presence of matted adhesions (short arrow) between the small bowel loops
Figure 12
Figure 12
Sagittal and coronal T2W MR images showing a large hyperintense lesion which confirms to the shape of peritoneal cavity. Presence of several peritoneal adhesions are seen along the lesion extending up to the ovarian surface (marked as *). Entrapped ovaries in the centre of lesion constitute the ‘spider-in-web sign to diagnose peritoneal inclusion cyst
Figure 13
Figure 13
Proposed imaging-based scoring system to estimate the total adhesion burden in the peritoneal cavity. This system is based on the morphological parameters which help to diagnose the adhesions on routine CT and MRI

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