CASE 17588 Published on 13.01.2022

An unusual cause of loin to groin pain: Pelvic varices with pelvic vein thrombosis.

Section

Genital (female) imaging

Case Type

Clinical Cases

Authors

Jineesh Thottath,Aswathy Arakkal Kootapanakkal Narayanan

Southend University Hospital NHS Foundation Trust, Essex, United Kingdom

Patient

3 years, female

Categories
Area of Interest Abdomen, Pelvis, Vascular ; Imaging Technique CT
Clinical History

A previously well 35-year-old lady presented with acute loin to groin pain on the left side.

Imaging Findings

An ultrasound evaluation of the urinary tract was unremarkable.

A CT urogram was performed which revealed several dilated vascular channels and spaces in the pelvis, more towards the left side keeping with pelvic varices.

The left ovarian vein was dilated.

In addition; filling defects were noted in the left internal iliac vein branches extending into the varices suggestive of thrombosis.
A diagnosis of pelvic varices with acute pelvic vein thrombosis was made.

A Doppler evaluation of the lower limbs excluded any deep vein thrombosis in the region.

The lady subsequently improved on analgesics and anticoagulants and was discharged.

Discussion

Background

Isolated thrombosis of the pelvic veins is uncommon, accounting for approximately 2% of all lower extremity DVT [1, 2]. Usually associated with thrombosis of ovarian vein; they are mostly encountered in postpartum setting [3]. Other associations are malignancy, hypercoagulable states, pelvic inflammatory disease, inflammatory bowel disease, sepsis and recent pelvic or abdominal surgeries [4, 5].

Clinical perspective

Pelvic vein thrombosis presents with nonspecific clinical features and thus is not a straightforward diagnosis [6]. Loin or pelvic pain is a common presenting symptom. Others include fever and a palpable pelvic mass if ovarian vein involvement has caused swelling of the ovary [7].

These are not particularly suggestive and hence imaging plays a key role in establishing the diagnosis.

Imaging perspective

Contrast-enhanced CT evaluation of abdomen and pelvis, as well as MR venogram, are good radiological tools in detecting and estimating the extent of pelvic vein thrombosis. The involved veins are often dilated with the thrombus producing filling defects in the otherwise opacified lumen of the veins [6].

Outcome

Undue delay in the diagnosis of pelvic vein thrombosis and failing to initiate treatment in time can lead to potentially life-threatening complications, such as thrombus extension into the IVC and further pulmonary embolism. The incidence of pulmonary embolism is estimated to be 25% in untreated patients with mortality reaching about 4% [8, 9].

Although pelvic vein thrombosis can resolve spontaneously, given the potential for catastrophic consequences, anticoagulation is usually recommended [10].

Take-home message

Although rare, pelvic vein thrombosis is one with potential life-threatening complications and so it’s prudent to include this among the list of differentials especially in a female patient presenting with lower quadrant pain once the common conditions are ruled out. MRV and contrast-enhanced CT images are the most appropriate modalities that aid in making the diagnosis. Overlooks and delays in making the diagnosis can lead to life-threatening conditions, such as pulmonary embolism. A high index of suspicion, timely imaging and prompt treatment are advisable to avert such consequences.

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Pelvic varices with pelvic vein thrombosis
Pelvic haemangioma/ vascular malformation
Lower limb deep vein thrombosis with pelvic extension
Pelvic malignancy with venous thrombosis
Final Diagnosis
Pelvic varices with pelvic vein thrombosis
Case information
URL: https://www.eurorad.org/case/17588
DOI: 10.35100/eurorad/case.17588
ISSN: 1563-4086
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