AJR 2004; 183:737-742
© American Roentgen Ray Society
Obstetric-Gynecologic Imaging |
Sonography of the Abnormal Fallopian Tube
Ofer Benjaminov1,2 and
Mostafa Atri1
1 Department of Medical Imaging, Sunnybrook and Women's College Health Science
Centre, University of Toronto, 2075 Bayview Ave., Toronto, ON M4N 3M5,
Canada.
2 Present address: Department of Medical Imaging, Rabin Medical Center,
Beilinson Campus, Sackler School of Medicine, University of Tel-Aviv,
Jabutinsky St., Petach Tikva 49100, Israel.
Received October 6, 2003;
accepted after revision March 8, 2004.
Address correspondence to M. Atri
(mostafa.atri{at}swchsc.on.ca).
The fallopian tubes run along the superior margins of the broad ligaments
and are approximately 10 cm long. The fallopian tube has a diameter ranging
from 1 to 4 mm and can be classified into four segments from the proximal
uterine end to the distal fimbriated end adjacent to the ovary. The
interstitial segment is the component that traverses the uterus. The isthmic
segment is the proximal constricted segment. The ampullary segment consists of
the intermediate portion. The infundibular segment opens to the peritoneal
cavity and has its fimbriated end attached to the ovary.
The fallopian tubes are not usually visualized on a routine transvaginal
sonographic examination unless outlined by fluid. However, the interstitial
segment may be identified on transvaginal sonography as an echogenic line
arising from the endometrial canal and extending through the uterine wall.
When surrounded by intraperitoneal fluid, the remaining segments of the
fallopian tubes are commonly seen as tubular structures extending between the
uterus and the ovaries. Fallopian tubes are best visualized on sonography when
thickened or fluid-filled as a result of pelvic inflammatory disease, torsion,
ectopic pregnancy, or tumors.
Pelvic Inflammatory Disease
Pelvic inflammatory disease includes a wide spectrum of diseases:
endometritis, salpingitis, perioophoritis, and tuboovarian abscess. It is
usually due to a gynecologic infection but may also be attributed to direct
extension from an inflamed appendix, diverticulitis, or other pelvic
inflammatory conditions.
When pelvic inflammatory disease is suspected, sonography is the first
imaging technique performed to determine the extent of the disease. A
thickened fallopian tube, usually bilateral, is the main diagnostic feature
(Figs. 1A and
1B). The thickened fallopian
tube may or may not be associated with debris containing tubal distention
indicative of a pyosalpinx (Figs.
2A,
2B, and
2C). The thickened portion of
the tube is generally located close to the ovary. The ovary itself may be
enlarged, and the surrounding fat may show increased echogenicity due to
edema. In more severe cases, hypoechoic areas are seen in the fat and there
may be an associated ovarian abscess.
View larger version (164K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —Sonographic features of pelvic inflammatory disease with thickened
fallopian tubes in 38-year-old woman. Axial (A) and sagittal (B)
transvaginal sonograms of right adnexa show normal ovary (OV) relatively close
to thickened fallopian tube (arrows). Note elongated nature of
thickened tube on sagittal view (arrows and crosshairs,
B). Similar findings were present in left adnexa.
|
|
View larger version (169K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Sonographic features of pelvic inflammatory disease with thickened
fallopian tubes in 38-year-old woman. Axial (A) and sagittal (B)
transvaginal sonograms of right adnexa show normal ovary (OV) relatively close
to thickened fallopian tube (arrows). Note elongated nature of
thickened tube on sagittal view (arrows and crosshairs,
B). Similar findings were present in left adnexa.
|
|
View larger version (157K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —Sonographic features of pelvic inflammatory disease with pyosalpinx
and surrounding inflamed fat. Thickened fluid-filled fallopian tube
(arrows) with solid-appearing internal echoes (asterisks) is
consistent with pyosalpinx.
|
|
View larger version (123K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —Sonographic features of pelvic inflammatory disease with pyosalpinx
and surrounding inflamed fat. Differentiation between pus and wall of
fallopian tube (arrows) is difficult when they have same
echotexture.
|
|
View larger version (147K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —Sonographic features of pelvic inflammatory disease with pyosalpinx
and surrounding inflamed fat. Combination of hypoechoic (arrows) and
hyperechoic (asterisks) fat surrounds pyosalpinx (pyosalpinx itself
is not seen on this image). Degree of inflammation is usually indication of
infection and is unusual in other causes of acute gynecologic distress, but
may be seen with other inflammatory causes such as Crohn's disease, acute
appendicitis, and diverticulitis.
|
|
Hydrosalpinx
A hydrosalpinx results from an accumulation of secretions when the tube is
occluded at its distal end or at both ends. On rare occasions, transient
distention of the fallopian tubes occurs because of retrograde passage of
blood from the uterus without complete distal occlusion. A hydrosalpinx is
most commonly a sequela of pelvic inflammatory disease or may develop in
patients undergoing tubal ligation
[1] or ovulation induction
[2]. A unilateral or bilateral
hydrosalpinx may occur in women after hysterectomy when only the fallopian
tubes are left to protect the blood supply to the ovary
[3]. This is because of
accumulation of tubal secretions caused by surgical blockage proximally and
adhesion-related blockage distally. Other causes include primary or secondary
tumors of the fallopian tubes
[4].
On sonography, the dilated fallopian tube presents as a thin- or
thick-walled tubular fluid-filled structure that may be elongated or folded
(Figs. 3A,
3B, and
3C). Longitudinal folds that
are present in a normal fallopian tube may become thickened in the presence of
a hydrosalpinx. The dilated fallopian tube may or may not show longitudinal
folds. These longitudinal folds are pathognomonic of a hydrosalpinx (Figs.
3A,
3B,
3C and
4A,
4B,
4C,
4D). If the elongated nature
of these folds is not noted, they may be mistaken for mural nodules of an
ovarian cystic mass (Figs. 4A,
4B,
4C, and
4D). Identification of a
separate ovary helps distinguish a hydrosalpinx from a cystic ovarian mass, an
important distinction because malignancy is rare with an extraovarian cystic
adnexal mass. A significantly scarred hydrosalpinx may present as a
multilocular cystic mass with multiple septa creating multiple compartments
(Figs. 4A,
4B,
4C, and
4D). These septa are generally
incomplete, and the compartments can be connected. However, with more
pronounced scarring, differentiation from an ovarian mass may not be possible
[5]. Potential pitfalls in the
diagnosis of hydrosalpinx include paratubal, paraovarian, or perineural cysts
(Figs. 5A and
5B). In some cases, CT or MRI
may be helpful to differentiate these conditions from a hydrosalpinx
(Fig. 5B).
View larger version (170K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3A. —Variable appearance of different segments of hydrosalpinx on
transvaginal sonography in 34-year-old woman. Sagittal sonogram reveals
elongated thickened proximal segment of fallopian tube (arrows).
|
|
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3B. —Variable appearance of different segments of hydrosalpinx on
transvaginal sonography in 34-year-old woman. Sagittal (B) and
transverse (C) sonograms show distended funneled distal end of
hydrosalpinx (arrows, C), separate from ovary (ov in
C). Note nodular appearance of longitudinal folds at junction of
collapsed and distended segments (arrows, B).
|
|
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3C. —Variable appearance of different segments of hydrosalpinx on
transvaginal sonography in 34-year-old woman. Sagittal (B) and
transverse (C) sonograms show distended funneled distal end of
hydrosalpinx (arrows, C), separate from ovary (ov in
C). Note nodular appearance of longitudinal folds at junction of
collapsed and distended segments (arrows, B).
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —Complex hydrosalpinx. Transverse transvaginal sonograms in
42-year-old woman show multicystic mass with multiple apparent septations
(arrows, A) representing wall of folded scarred dilated
fallopian tube. Note vascularity in one septum (arrowhead,
B).
|
|
View larger version (53K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —Complex hydrosalpinx. Transverse transvaginal sonograms in
42-year-old woman show multicystic mass with multiple apparent septations
(arrows, A) representing wall of folded scarred dilated
fallopian tube. Note vascularity in one septum (arrowhead,
B).
|
|
View larger version (108K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4C. —Complex hydrosalpinx. Sagittal sonogram in 45-year-old woman shows
folded hydrosalpinx with multiple compartments (asterisks). Depending
on complexity, it may or may not be possible to connect these
compartments.
|
|
View larger version (143K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4D. —Complex hydrosalpinx. Sagittal sonogram in same patient as in
C shows apparent nodules (arrows) in hydrosalpinx. These
correspond to longitudinal folds seen en face. Ovary (ov) is relatively close
to distended fallopian tube.
|
|
View larger version (145K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5B. —Perineural (Tarlov's) cysts mimicking hydrosalpinx in 45-year-old
woman. CT scan shows location of cysts (arrows) in pyriformis muscle
(asterisks). On other images, these cysts extend into sacral
foramina.
|
|
Torsion
Torsion of the fallopian tube is an uncommon condition in both pre- and
postmenopausal women. The predisposing factors are either intrinsic tubal
abnormalities, including tortuousity, a hydrosalpinx, tubal ligation, or a
tumor of the fallopian tube or extrinsic abnormalities, including a paratubal
mass, peritubal adhesions, or uterine enlargement compressing or obstructing
the tubes [6].
Clinical presentation is similar to ovarian or combined ovarian and tubal
torsion, with acute intense ipsilateral pelvic pain associated with nausea and
vomiting. Sonography may show a thick-walled elongated cystic mass
corresponding to a distended fallopian tube (Figs.
6A,
6B and
7A,
7B,
7C). The distended fallopian
tube may be associated with hematosalpinx. The twisted thickened edematous
component of the fallopian tube may be evident in torsion (Figs.
7A,
7B, and
7C). On Doppler sonography, if
this component remains vascular, it may show twisted vessels similar to the
"twisting" sign reported with ovarian torsion. In the absence of
these, differentiation from an uncomplicated hydrosalpinx may be difficult.
The complete absence of flow in this structure is a confirmatory finding.
However, the presence of flow does not exclude the diagnosis. Persistent
arterial flow and absent venous flow may be seen in the early and incomplete
stages of torsion (Fig. 6B).
Moreover, the persistence of flow in the presence of torsion may be explained
by the dual blood supply to the adnexa from both ovarian and uterine
vessels.
View larger version (141K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 6A. —Acute isolated fallopian tube torsion in 36-year-old woman.
Transvaginal sonogram shows peripheral cystic structures (asterisks)
surrounding central star-shaped echogenic solid component (arrows).
Central solid component corresponds to edematous mesosalpinx (MS) and
peripheral cystic components to distended tube containing debris wrapped
around mesosalpinx.
|
|
View larger version (63K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7A. —Acute isolated fallopian tube torsion in 28-year-old woman.
Transvaginal sonogram shows compressed ovary (ov) adjacent to cystic structure
that represents dilated distal end of fallopian tube (HSX) with apparent
asymmetric thickening of its walls (arrows) representing ovary.
|
|
View larger version (84K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 7C. —Acute isolated fallopian tube torsion in 28-year-old woman. Color
Doppler sonogram shows proximal end of tube, adjacent to torsion, is vascular
but distal end, seen in A, is avascular.
|
|
Neoplasm
Primary malignant tumors of the fallopian tubes are rare, with a reported
prevalence of 0.3% of gynecologic malignancies. Adenocarcinoma is the most
frequent primary neoplasm of the fallopian tube, which usually presents in the
sixth decade of a patient's life.
The preoperative diagnosis of primary carcinoma of the fallopian tube is
often not made because of a combination of low index of suspicion and
nonspecific imaging features in some cases. Although the symptoms could be
nonspecific, the combination of vaginal discharge, pain, and an adnexal mass
should raise the suspicion of this diagnosis
[4]. Sonographic features could
also be nonspecific and overlap between benign- and malignant-appearing
adnexal masses. However, the presence of an elongated cystic mass,
corresponding to a dilated fallopian tube, and an intraluminal solid component
or mural nodularity is suggestive of this diagnosis (Figs.
8A,
8B, and
8C). A vascular solid
component on Doppler sonography helps differentiate between solid debris in
the fallopian tube and a neoplastic process
(Fig. 8C). Additional helpful
associated findings are ascites and intracavity uterine fluid.
Other tumors of the fallopian tube include metastasis from different
gynecologic malignancies (Figs.
9A and
9B), leiomyomas, teratomas,
and fibromas.
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9A. —Metastases to fallopian tube from endometrial carcinoma in
52-year-old woman. Sonogram shows multiple nodular lesions
(asterisks) are seen in wall of fallopian tube (arrows).
These nodules were vascular.
|
|
View larger version (154K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 9B. —Metastases to fallopian tube from endometrial carcinoma in
52-year-old woman. Sonogram shows large solid mass filling tube. Note thin rim
(arrowheads) of wall of fallopian tube surrounding mass
(crosshairs).
|
|
Ectopic Pregnancy
Transvaginal sonography in conjunction with evaluation of the serum
ß-hCG level is the initial test performed to diagnose ectopic pregnancy.
Clinical presentation of patients with ectopic pregnancy is nonspecific and
includes a combination of pain, vaginal bleeding, and a palpable tender
adnexal mass. However, high-risk asymptomatic patients may be evaluated for
ectopic pregnancy. Ninety-five percent of ectopic pregnancies are located in
the isthmic, ampullary, or infundibular portion of the fallopian tube. The
remaining 5% are interstitial (Fig.
10), ovarian, abdominal, or cervical
[7]. The products of conception
grow into the mucosal or serosal surface of the fallopian tubes, thus causing
distortion and expansion of the fallopian tubes often associated with bleeding
into the lumen [7]
(Fig. 11B).
View larger version (99K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 10. —Interstitial ectopic pregnancy in 25-year-old woman. Longitudinal
transvaginal color Doppler sonogram of uterus shows interstitial pregnancy
surrounded by vascular ring (straight arrows) situated in right
cornu. Interstitial ectopic pregnancy is located in cornua of uterus and can
be recognized on transvaginal sonography by presence of myometrium around
ectopic pregnancy (curved arrows) and extension of endometrium to
border of ectopic pregnancy (arrowheads).
|
|
View larger version (150K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 11B. —Ectopic pregnancy associated with intratubal bleeding in 32-year-old
woman. Sonogram shows tubal mass or hematosalpinx (arrows) caused by
blood within distended tube surrounded by free fluid (asterisks). On
Doppler sonography, this mass was avascular.
|
|
A live embryo outside the uterus, seen in only 8–26% of ectopic
pregnancies [8], is the only
pathognomonic sign with which to diagnose ectopic pregnancy. The most
sensitive sonographic sign of tubal ectopic pregnancy is the presence of an
extraovarian adnexal mass consistent with a tubal mass. This finding is shown
to be highly specific in the proper clinical setting
[9]. This mass may contain a
gestational sac resulting in a tubal ring. However, it may be completely solid
with a round or elongated shape representing a hematosalpinx due to a
combination of blood clots and products of conception (Figs.
11A and
11B). Interstitial ectopic
pregnancy is recognized by the extension of the endometrial lining to the
margin of the ectopic pregnancy, reported as "interstitial line"
sign [10]
(Fig. 10).
View larger version (149K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 11A. —Ectopic pregnancy associated with intratubal bleeding in 32-year-old
woman. Longitudinal transvaginal sonogram shows ectopic pregnancy within
fallopian tube. Note "tubal ring" of ectopic pregnancy when
gestational sac (arrows) is present.
|
|
Other sonographic findings include an empty uterus and free intraperitoneal
fluid or blood clots in the pelvis
[8].
Doppler imaging may assist in the evaluation of ectopic pregnancies as a
complementary tool to gray-scale imaging. The Doppler indices of ectopic
pregnancies are generally in the low resistive index (RI) range; however, they
may vary from a low RI to a high RI overlapping with RI values of a corpus
luteum cyst of ovary [7]. A
recent study shows that an RI below 0.39 and above 0.7 differentiates ectopic
pregnancy from a corpus luteum cyst
[9]. Although the presence of
high vascularity in an extraovarian adnexal mass increases the confidence of
ectopic pregnancy diagnosis, low or absent vascularity should not deter one
from making this diagnosis.
Acknowledgments
We thank Carole Leduc for her assistance in the preparation of this
manuscript.
References
- Russin LD. Hydrosalpinx and tubal torsion: a late complication of
tubal ligation. Radiology1986; 159:115
-116[Abstract/Free Full Text]
- Schiller VL, Tsuchiyama K. Development of hydrosalpinx during
ovulation induction. J Ultrasound Med1995; 14:799
-803[Abstract]
- Morse AN, Hammer RA, Walter AJ, Baker S, Magtibay PM. Does
hysterectomy without adnexectomy in patients with prior tubal interruption
increase the risk of subsequent hydrosalpinx? Am J Obstet
Gynecol 2002;187:1483
-1485[Medline]
- Kawakami S, Togashi K, Kimura I, et al. Primary malignant tumor of
the fallopian tube: appearance at CT and MR imaging.
Radiology1993; 186:503
-508[Abstract/Free Full Text]
- Atri M, Nazarnia S, Bret PM, Aldis AE, Kintzen G, Reinhold C.
Endovaginal sonographic appearance of benign ovarian masses.
RadioGraphics1994; 14:747
-760[Abstract]
- Richard HM 3rd, Parsons RB, Broadman KF, Shapiro RS, Yeh HC.
Torsion of the fallopian tube: progression of sonographic features.
J Clin Ultrasound1998; 26:374
-376[Medline]
- Atri M, Leduc C, Gillett P, et al. Role of endovaginal sonography
in the diagnosis and management of ectopic pregnancy.
RadioGraphics1996; 16:755
-774[Abstract]
- Bau A, Atri M. Acute female pelvic pain: ultrasound evaluation.
Semin Ultrasound CT MR2000; 21:78
-93[Medline]
- Atri M. Ectopic pregnancy versus corpus luteum cyst revisited: best
Doppler predictors. J Ultrasound Med2003; 22:1181
-1184[Abstract/Free Full Text]
- Ackerman TE, Levi CS, Dashefsky SM, Holt SC, Lindsay DJ.
Interstitial line: sonographic finding in interstitial (cornual) ectopic
pregnancy. Radiology1993; 189:83
-87[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
L. Burke
Hydrosalpinx in a Woman With a Partial Hysterectomy
Journal of Diagnostic Medical Sonography,
July 1, 2007;
23(4):
204 - 207.
[Abstract]
[PDF]
|
|
|
|
|
|
|
E M Anderson and H K Bungay
Imaging investigation of acute right iliac fossa pain
Imaging,
December 1, 2006;
18(4):
257 - 267.
[Abstract]
[Full Text]
[PDF]
|
|
|
