Clinical History
40-year-old female patient with long-standing history of Crohn’s disease, including multiple previous surgical procedures (subtotal colectomy, ileal resections) and ileostomy, hospitalised with high fever due to left-sided acute pyelonephritis.
During the last year, she had been suffering from recurrent urinary infections, dysmenorrhoea, malaise and progressive weight loss.
Imaging Findings
At another hospital, the patient had ureteral J-stent positioning to relieve left-sided hydronephrosis. Transferred to our institution, multidetector CT urography was performed using triple-bolus technique to obtain simultaneous arterial, nephrographic and excretory acquisitions with limited radiation dose. Poorly functioning left kidney was confirmed, with ureteral stent in place. As an incidental finding, a fairly sized (7 cm) septated collection with thin walls and fluid-like attenuation was seen in the right adnexal region. The consultant gynaecologist excluded need for immediate surgical removal of the tubo-ovarian collection.
Malabsorption due to short bowel syndrome and chronic sepsis was clinically diagnosed and treated supportively. Two months later, after clinical and laboratory improvement surgical recanalisation and ileostomy closure was planned and preoperative MDCT enterography was requested. Moderate enlargement of the right-sided adnexal collection was detected, with appearance of mural enhancing thickening and of a smaller contralateral collection. During surgery, bilateral hydrosalpinx was confirmed.
Discussion
Female patients affected with Crohn’s disease (CD) commonly suffer from reproductive tract disorders, including highly prevalent altered fertility and menstrual cycle, psychosocial and sexual impairment [1]. Ano- and rectovaginal fistulas represent the most usual identifiable anatomic abnormalities, whereas sporadic cases of entero-salpingeal fistulas have been reported, resulting from direct extension of fistulising transmural intestinal disease [1-4]. Furthermore, chronic CD-related pelvic inflammation and previous surgical procedures can lead to the formation of adhesions, which can cause fallopian tubes obstruction and ultimately result in mono- or bilateral hydrosalpinx [5, 6].
Nowadays, patients with inflammatory bowel diseases often undergo cross-sectional imaging studies throughout their lifelong course, including urgent contrast-enhanced multidetector CT during acute CD exacerbations, and volume-challenge CT / MRI enteroclysis or peroral enterography techniques to assess extent, activity and postoperative recurrences of intestinal disease along with extraintestinal fistulising or abscessual complications [7].
Despite their not-negligible incidence, gynaecological abnormalities in CD patients are often clinically unsuspected or underestimated compared to the dominant systemic or intestinal symptoms, and may be incidentally detected on cross-sectional imaging performed to investigate the inflammatory bowel disease. Therefore, as this case exemplifies, when interpreting CD diagnostic imaging studies, adnexal abnormalities should be identified, in order to provide appropriate treatment choice through gynaecological consultation, and prevention of further complications [5, 7].
On CT or MR images, hydrosalpinx appears as a dilated juxta-uterine structure, with internal fluid-like attenuation values and signal intensity, with a tubular configuration that may be disclosed on multiplanar reformations. Markedly dilated fallopian tubes become indistinguishable from the ovaries. Excretory phase CT acquisition allows visualisation of the posteriorly located ureters that should be preoperatively identified. Complex fluid collection with internal septations and thickened enhancing walls should suggest further complications such as pyosalpinx or tubo-ovarian abscess [5, 6].
Patients’ medical history and coexistent intestinal abnormalities should be considered to allow the differentiation from manifestations of unspecific pelvic inflammatory disease (PID), endometriosis, previous tubal ligation, hysterectomy without salpingo-oophorectomy, or primary ovarian disease particularly a cystic neoplasm [1].
Treatment of CD-related tubo-ovarian abnormalities usually requires combined surgical approach including bowel resection along with salpingectomy of the affected fallopian tube [2, 4].
Differential Diagnosis List
Bilateral hydrosalpinx, pelvic adhesions from surgically treated Crohn's disease
Pelvic inflammatory disease (PID)
Endometriosis
Final Diagnosis
Bilateral hydrosalpinx, pelvic adhesions from surgically treated Crohn's disease
