Ultrasound of the Fallopian Tube - HD

Introduction

I'm Dr. Mindy Horo from Philadelphia, Pennsylvania.
I work at Einstein Medical Center.
It's my pleasure today to give you a talk on the fallopian tube ultrasound of the fallopian tube.

This is the outline of the talk.
First we'll discuss the embryology and the appearance of normal fallopian tubes and then a significant amount of discussion of fallopian tubes in pelvic inflammatory disease, followed by various causes of hydrosalpinx, tumors, torsion issues related to infertility.
And then at the end, some lookalikes, other tubular structures in the pelvis.

Embryology and Normal Fallopian Tubes

The fallopian tubes form at around five to six weeks from the paramesonephric ducts.
The cranial portion becomes the fallopian tubes where the caudal portion fuses to form the uterus.
The cranial end is funnel shaped and this is the portion that is open to the peritoneum near the ovary.

As far as congenital anomalies of the fallopian tubes, there really aren't that many, paratubal cysts, also known by the fancy title of hydatid of Morgagni are small portions of the paramesonephric ducts that did not go on to contribute to the tubes and are vesicular appendages.
These are common and we'll show some examples of them.
Other congenital abnormalities have to do with an ectopic tube, and this is usually when the fallopian tube is in an inguinal hernia with the ovary.

The normal fallopian tubes, as you know, extend from the ovary toward the uterus or vice versa, if you will, within the broad ligament.
The main purpose is to transport ovum from the ovary to the uterus.
The length of the fallopian tube is about 10 to 12 centimeters and one to four millimeters in diameter.
The fimbriae are at the open end and they are suspended over the ovary to capture the released ovum.

Four specific anatomic segments make up the fallopian tube.
The interstitial portion is that piece of the fallopian tube that is within the myometrial cornua within the muscle of the uterus.
The isthmic portion coming out of the uterus is the narrowest portion of the tube.
Accounting for about half the ampullary portion closer to the ovary is the widest segment, and this is another half of the tube.
And then there's the small funnel shaped infundibulum overlying the ovary.

The composition of the wall of the tube is such that the mucosa is a specialized kind of mucosa with finger-like projections or plicae.
Which you'll see in examples of the epithelium of the tube has both ciliated and non-ciliated columnar cells.
And the purpose of this ciliated epithelium and the plicae are to propel the ovum towards the uterine cavity.
And in addition, fluid from the uterus is propelled out of the tube into the peritoneal cavity.

One can visualize normal fallopian tubes with ultrasound.
It often helps to have a small amount of fluid, or in this case there was a moderate amount of fluid from rupture of a cyst to outline the fallopian tube.
And this would be the interstitial portion.
And here you can see the thinner isthmic portion, ampullary and fimbriated end of the fallopian tube.

The portions within the uterus are a bit more difficult to see, but sometimes if you just catch them right, you can visualize where the interstitial portion of the fallopian tubes are within the myometrium of the uterus, particularly if you follow the endometrium towards this point.

The cine clip on the right shows you the ovary and next to it you can see a portion of the fallopian tube in particular.
You can actually see those floaty looking fimbriated ends of the tube right near the ovary.
In this one, again, here's the fallopian tube coming in and out of view as it surrounds the ovary.
And this patient has a small paratubal cyst.
There it is, there's a second one, and you can see a larger paratubal cyst on the other side.
They're very, very common and if you cannot see the fallopian tube, you just get a sense of a cyst seeming to float in the middle of nowhere.
But generally speaking, it's connected to the tube.

This is an example of a newborn who has an inguinal hernia, which contains ovary.
There's some follicles in it, and here in cross-section, here's the ovary, and next to it is the fallopian tube, which is also herniated.

Pelvic Inflammatory Disease

Now let's turn to pelvic inflammatory disease.
Because this is a very common disease and a common disease to involve the fallopian tubes, there are fewer than maybe three quarters of a million new cases of acute pelvic inflammatory disease in the United States per year.
Overall, we believe the rates of acute PID are decreasing, but there's probably a significant background of subacute or chronic disease.

Pelvic inflammatory disease we now know is a polymicrobial infection once thought to only be due to gonorrhea and then to chlamydia.
Both of these are involved and once there has been epithelial damage to the fallopian tubes, super infections with a variety of other opportunistic organisms can occur.

The way that pelvic inflammatory disease gets to the fallopian tubes is after an initial endometritis, the inflammation leads to tubal inflammation, which causes adhesions within the tubes and eventually spread through the tube to the peritoneum or obstruction of the tube and dilatation.
If there is spread out of the tube towards the peritoneum, it often involves the ovary.

In clinical situations, fewer than 50% of cases are the symptoms alone sufficient to make the diagnosis of pelvic inflammatory disease and therefore frequently people turn to sonography to help corroborate the diagnosis or to find other diagnoses for a pelvic inflammatory disease and ultrasound, the hallmark of the disease of making the diagnosis is an abnormal fallopian tube.

Signs of Abnormal Fallopian Tubes in PID

So what happens when the fallopian tube becomes abnormal?
The key thing here is to make sure that the structure in question the abnormal structure is separate from the ovary.
And once you do that, then it's presumably going to be the fallopian tube.
And there are a variety of signs which have been described including the waist sign with diametrically opposed indentations of the wall.
The incomplete septum sign is the protrusion coming from one wall but not reaching the opposite wall.
And these are particular findings characteristic of fallopian tubes when the wall of the fallopian tube is thick, often we can see a cogwheel sign when you look at the tube in cross-section and as the wall gets thinner because of more dilatation or from chronic disease, you get an appearance of beads on a string where the little thickened plicae are the beads on the string of the thin walled fallopian tube.

Other findings, which you may or may not notice, is that if the tube is filled with echoes, it could even look solid.
There may be a fluid debris level.
Very rarely you can have gas in the fallopian tube with use of eclipse and something called 3D inverted imaging.
It is often easier to portray the abnormality of the fallopian tube separate from the ovary.

These are diagrams demonstrating the different signs that I've described.
If you take this to be the normal fallopian tube on cross-section, and you can see these would be the little endometrial plica folds as the tube becomes thickened, so do the folds and you get the cogwheel sign.
If the tube becomes more and more dilated and the wall is thinner, the endometrial plica folds are also compressed, but you get this appearance of beads on a string, so this may look like a simple cystic structure, but these tiny little beads give it away as the fallopian tube.

When the tube is normal here we're seeing a normal tube.
As it becomes obstructed, the tube dilates and folds back on itself.
As you can see here, sort of like a sausage and these incomplete septa or waist sign becomes apparent.

Examples of Dilated Tubes in PID

So what do some of these look like?
This is an example of a very slightly dilated fallopian tube on cross section.
The lumen is filled with low level echoes and it's somewhat hard to distinguish from the wall, but using color can be helpful in the acute situation because the wall is often hyperemic.
So the color outlines the wall actually, and you can see the fluid inside.
The key here, of course, is that the ovary is separate from this structure and there's the cine clip on the side here showing you the fallopian tube and the separate ovary off to the side.

Again, a slightly dilated tube separate from an ovary CT is not uncommonly ordered in these patients, not because it would be the primary diagnostic modality, but CT is just very often used in the emergency room.
The physicians may think the patient has appendicitis or diverticulitis, and if they think that more likely than pelvic inflammatory disease, CT may be the study that is ordered.
So it's useful to see what's going on in one and compare to the other.

Here you can see the uterus and these very brightly enhancing structures that look curvilinear and tube-like are indeed the fallopian tubes.
Not dilated per se, but just enhancing brightly.
This would correspond to the hyperemia we saw in the ultrasound image.
Often better seen actually on CT is this slight inflammation.
As you can see across the front here in the prevesical space, in coronal reformats, this is the uterus.
Here's one fallopian tube and here's the other.

As the tube becomes more dilated, it's easier to see.
And you can see in this still image here the fallopian tube.
And you can also see in this cine clip the tube next to the ovary.
There it is winding around, curving back on itself next to and separate from the ovary, which is quite normal.

These are examples of the cogwheel sign.
Three different patients with increasing degrees of dilatation.
So here we have a little bit of fluid in the tube thickened endometrial plica folds.
Here there's a little more fluid, again, the folds and once again even more dilatation, but still thickened endometrial plica folds.
Do not mistake these folds for mural nodules and be concerned that there is an epithelial neoplasm.

The cogwheel sign can also be seen on CT.
As you can see here, the endometrial plica folds are a bit harder to see because they're so, they're still relatively thin.
Again, here's the inflammation.
And similarly, in a path specimen, a cross section of the tube, this would be the dilated lumen, and here are the thickened endometrial plica folds.

Progression to Salpingitis, Pyosalpinx, and Tubo-Ovarian Abscess

As the disease worsens.
The salpingitis, which would just be an inflamed swollen tube, can go on to an obstructed tube filled with pus, which we would call therefore a pyosalpinx.
If the pus leaks out and sticks around the tube and the ovary is stuck all into one structure, this would be called a tubo-ovarian complex.
In this situation, the tube is adherent to the ovary, but the ovary is still distinct and can be measured eventually.
The point comes where the abscess involves the ovary and one can no longer distinguish tube from ovary.
The whole thing is measured as one and called a tubo-ovarian abscess.
Obviously there are a variety of other complications, which you may or may not be able to see with ultrasound, peritonitis rupture of a TOA, ileus Fitz-Hugh-Curtis and hydronephrosis, which we won't be discussing.

So what do dilated pus filled tubes look like?
Here's an example. You can see a large portion of the tube, curving back on itself.
Here's the incomplete waist sign.
The tube is filled with low level echoes in a very nice fluid debris level, and here it is again.
While this portion may look like a mass, you can see in the smaller portion those endometrial plica folds are highly characteristic of the fallopian tube and once again, the ovary is separate.

Here are examples of bilateral pyosalpinx, this one with the hyperemia in the color and the thickened wall.
Here's the other one.
These are the path specimens of these thick wall tubes which were filled with pus in this patient who had a total abdominal hysterectomy and salpingo-oophorectomy.

A tubo-ovarian complex could look like this.
Again, you can make out the ovary.
Here are the little follicles in it and this very thick structure all around.
It is a slightly dilated, very thick walled fallopian tube filled with low level echoes.
Again, here it is ovary with tube curling around it and stuck to it and the tube is very hyperemic in this situation of acute pelvic inflammatory disease.

Eventually, as I said, you can no longer distinguish tube from ovary and this patient has bilateral tubo-ovarian abscess.
You would measure the whole structure here and here and the patient happened to have a CT scan and you can see one on the right and one on the left with the intervening inflammation.

This is a unusual example.
In this case, there was presumably a polymicrobial superinfection and the patient developed gas in the fallopian tubes.
Now on CT you can see the gas fluid level very nicely because we were rolling the patient around to image her, the bubbles bubbled up and you can see individual tiny little bright echoes.
And the other side there was one little dot of air and I don't really think we appreciated it.
Maybe it was here, but this is a rare occurrence now.

Recurrent and Chronic PID

Patients often present with multiple episodes of pelvic inflammatory disease with in between treatment, and you need to remember that in a patient who has had at least one episode of pelvic inflammatory disease, the fallopian tube may never completely go back to normal.
It might not be dilated or it might be, but then when there's a second infection, the tube can out of proportion look very abnormal, whereas the patient may not be as sick as the ultrasound would lead you to believe.
That's because the tube already is damaged and maybe dilated and it's just been superinfected.

As in this case where the patient had right hydrosalpinx at the end of her episode of treated pelvic inflammatory disease symptoms recurred and the tube got significantly dilated and filled with low level echoes.
The patient had a CT, here's the dilated tube, not a lot of inflammation here, and the patient really wasn't that sick.
The images looked worse than the patient.

And as I alluded to in that last one, chronic abnormalities can occur with treated pelvic inflammatory disease.
There's not a lot of literature about what happens when you treat pelvic inflammatory disease, but from the little that there is, and partly from my experience, it can take just a few days for complex fluid and inflammation to resolve, but adhesions can take quite a while to resolve.
If ever, it certainly can change from a pyosalpinx to a simple hydrosalpinx.

Occasionally patients who did not have a dilated fallopian tube during the acute stage can at some point in the future come and have just a simple hydrosalpinx if the tube went on to obstruct.
People feel that if the pyosalpinx does not resolve or even develops into a hydrosalpinx, it may be related to an incompletely treated infection.

Here are examples of dilated simple fluid-filled fallopian tubes, hydrosalpinx in two different patients.
The ovary is here and here's the tube curled back on itself.
A nice example of an incomplete waist sign.
Here's another simple tubular structure, which in cross section you can see the little endometrial plica folds, but the fluid is simple.

A hydrosalpinx forms because secretions are accumulating in the tube that has a distal obstruction.
If the obstruction in the tube was closer to the uterus, you wouldn't develop an interval hydrosalpinx.

You need to know, however, that a hydrosalpinx can be caused by a variety of other etiologies, and it does not necessarily signify that the patient has had PID.
So sometimes from tubal ligation situations of ovulation induction tumors and occasionally after a hysterectomy, if the tubes are left in place, a hydrosalpinx can occur.
Again, the key as in the acute situation is to find a separate ovary from the cystic tubular structure and to be able to rule out a cystic ovarian mass.

And here is an example of a post-menopausal woman.
She had a hysterectomy, but the tube was left on the CT scan which was performed.
Initially, we were concerned about a cystic neoplasm of the ovary because her ovaries were in place, but the ultrasound clearly shows the tubular nature of this structure and that it was just a simple hydrosalpinx.

Chronic Adhesions and Peritoneal Inclusion Cysts

There are other chronic abnormalities that can occur in patients after pelvic inflammatory disease, and this is an example of one of them.
This patient had had multiple prior episodes of PID and then came to us with chronic pain.
Absolutely not an acute situation.
And this is what we found you can see the ovary, there are follicles in it and it's labeled over ovary and the ovary surrounded by fluid.
The fluid, however, is not free and simple looking.
You can actually visualize adhesions extending from the ovary to the peritoneal wall as you see here.
Here's another of these adhesions and then there's another structure here, which is actually the dilated fallopian tube in cross-section.
It has the characteristic beads on a string.

So we've got an ovary surrounded by loculated fluid with adhesions, and there are adhesions to a dilated fallopian tube as well.

This is an example of a peritoneal inclusion cyst with a hydrosalpinx.
Here's an example of a patient who has peritoneal inclusion cyst without dilated tubes.
This is ovary. Here's the loculated fluid, and this is a normal fallopian tube with an adhesion.
On the other side, again, normal fallopian tube adhesions to the ovary and on CT, these are the normal fallopian tubes and the adhesions around the ovaries.

How does one get a peritoneal inclusion cyst?
It's due to the fluid that is produced by the ovary during ovulation, which is then entrapped and encapsulates the ovary due to the adhesions.
While pelvic inflammatory disease is one of the causes, there are a variety of others.
Prior surgery trauma, often patients with Crohn's disease or endometriosis.

The key for this diagnosis to differentiate it from an epithelial neoplasm is to demonstrate the ovary itself a normal ovary within the encapsulated cyst or in the wall of the cyst.
The differential diagnosis would include hydrosalpinx or paraovarian cysts.
The treatment for these is usually oral contraceptives to inhibit ovulation and hope that the fluid will resorb one can do lysis of adhesions, but of course that can create more adhesions.

Other Causes of Dilated Fallopian Tubes

Now let's turn to other causes of a dilated fallopian tube, and in this case we'll discuss hematosalpinx blood in the fallopian tube.
What kinds of things can cause this?
Well, there's endometriosis, uterine anomalies and tubal ectopic pregnancies.

Hematosalpinx Due to Endometriosis

Here's a patient with chronic pelvic pain, not an acute situation, no fever, no leukocytosis, and as you've learned, this would be a nice example of a dilated fallopian tube with an incomplete waist sign.
The tube is filled with very homogeneous, low level echoes.
The ovary is separate. This was on the left side.
On the right, there was a single round structure, not tubular, with the same fine homogeneous, low level echoes and a little bit of echogenic, more solid debris in the corner of the structure.
This is a classic finding of endometriosis with a left hematosalpinx and a right endometrioma.

Here's another example of a hematosalpinx secondary to endometriosis.
The still clips on the images on the left show the incomplete septum sign and waist sign.
And in the cine clip on the right, you can see how each of these LOEs of low level echoes connect one to the other, to the other and how beautifully one can demonstrate this Using a cine clip, the ovary can become stuck to the tube in endometriosis and so one can also get a tubo-ovarian complex, as one does in pelvic inflammatory disease.
And you see in this cine clip, there's the tube curling back on itself with a separate ovary.

Here is the path specimen in this patient.
She needed to go on and have a hysterectomy and salpingo-oophorectomy and so this is a tubo-ovarian complex with blood in the tube.
This is the dilated portion of the tube and the ovary is stuck on the side in one big complex from endometriosis.

In endometriosis, endometrial implants involve the tubes fewer than 10% of cases.
If the implants of endometriosis are within the lumen and they hemorrhage, that will cause a hematosalpinx if on the other hand, as is more common, the implants are on the outside of the tube.
On the serosal surface, this would not typically be visualized with ultrasound and wouldn't result in a dilated fallopian tube.

Hematosalpinx Due to Uterine Anomalies

Here's a another cause of a dilated blood filled fallopian tube.
This patient had an early pregnancy and was having some bleeding and pain and her physician palpated a left adnexal mass and was concerned for ectopic pregnancy.
If you look at this transverse transabdominal view, the uterus is here with the small gestational sac and there is a separate not connected structure.
On the left side, it has a dilated lumen filled with low level echoes with a level and a thick wall.

And if you scan serially through the right side, you can see what looks like a normal uterus.
And if you scan through the left side, there is this structure here, which might be a fallopian tube, but didn't really look tubular Further imaging showed that there was an addition to this atretic left horn of the uterus, which was obstructed a dilated fallopian tube next to it in a hematosalpinx.
And here you can see the hematosalpinx and there's the piece of the duplicated uterus.
It was an atretic horn which had dilated up from blood from related to being pregnant and the hormones affecting this side.
So the little atretic horn had dilated and the blood had gone retrograde into the fallopian tube causing a large palpable and tender adnexal mass.

When the patient was no longer pregnant.
You can see here, here's the main uterus, here's the slightly dilated atretic horn.
And the left tube had only developed into a hematosalpinx during pregnancy.

Hematosalpinx Due to Ectopic Pregnancy

Hematosalpinx from an ectopic pregnancy is clearly a common occurrence.
Sometimes it's hard to appreciate the tubal nature of the ectopic pregnancy, but here are four examples of different patients where you can actually see the tube.
Where here would be this tubular structure, the ectopic is here and the dilated tube, again, a dilated tube.
And these are other examples due to ectopic pregnancies.

Tumors: Fallopian Tube Carcinoma

Now let's turn to a much more unusual case, but one that is quite instructive and I will say, which we missed for quite a while, and hopefully you will learn from it and if have such a case may not miss it necessarily.

This 46-year-old woman came in with fairly acute left pelvic pain, and her initial imaging looked like this.
The uterus was fine.
We saw the ovary on the left and that looked normal.
And next to it was a structure which we interpreted as a dilated fallopian tube with low level echoes.
And we thought that she had a pyosalpinx with the tubo-ovarian complex.
She was treated with antibiotics for PID as an outpatient and then six months later she returned with recurrent pain.
Again, we imaged and saw a separate ovary and a structure next to it that looked again like a dilated fallopian tube.
This is the uterus and now there was fluid around the uterus and on the left and that fluid had low level echoes.
It was complex fluid, so we were actually concerned that she was ruptured or leaking from a tubo-ovarian complex into the peritoneum.
And again, she was treated for pelvic inflammatory disease and she went home.

She came back one month later with recurrent pain having appropriately taken her antibiotics.
At this point, again saw the ovary, the tubal structure was getting larger and larger.
There was increasing amount of fluid in the cul-de-sac with a fluid debris level.
And at this point the clinicians in the emergency room wondered if there was something more going on and wisely did not stop with ultrasound and went on and ordered a CT because she had been treated appropriately but was having recurrent problems.

So here in the pelvis you can see the uterus, both ovaries and the fallopian tube and there's free fluid as we saw on the ultrasound.
What we also saw on the CT and did not on the ultrasound is this structure here, which is an omental cake.
That's the greater omentum, which is infiltrated and solid appearing and that is due to tumor.
This patient turned out to have a primary fallopian tube carcinoma and we were misinterpreting it as pelvic inflammatory disease.

This is a rare occurrence.
The tumors usually arise in the ampullary portion of the tube near the ovary, and copious fluid is released, which leads to distension of the tube and a hydrosalpinx, the patients get pain when the tube dilates, but then often that fluid is discharged either out into the peritoneum or comes retrograde into the uterus and is discharged into the vagina and the symptoms abate.
This is known as Lateck's triad with intermittent vaginal discharge and colicky pain and an adnexal mass.
The appearance in symptoms overlap pelvic inflammatory disease, which is clearly far and away much, much more common.
And as a result, this situation is rarely diagnosed preoperatively ca 125 is often positive in these patients.

A relatively more recent theory actually is that the majority of serous epithelial neoplasms of the ovary of serous adenocarcinomas do arise from the fimbrial end, the fallopian tube and the tumor implants directly onto the ovary.
The theory for this is that in part because the cells of epithelial ovarian carcinoma are not actually primary to the ovary, but actually those cells of origin are within the fallopian tubes.
In addition, and this has been described in patients with the BRCA one and two mutations, it can occur in situ too.
Fallopian tube carcinoma has been detected when patients, these kinds of patients have a prophylactic salpingo-oophorectomy and so the in situ carcinoma is seen in the tube but not in the ovary.
Therefore, in these situations nowadays it's recommended to remove the entire uterus and entire fallopian tubes.

Here are examples of fallopian tubes that are abnormal.
They're not dilated but they're thick.
And both of these were involved with a carcinoma arising in the fallopian tubes.
You can see the complex fluid that's been discharged into the peritoneal cavity and this is the CT in this patient with a lot of complex fluid in an implant in the peritoneum and these thickened abnormal fallopian tubes.

Fallopian Tube Torsion

Now let's turn to another acute pain that could involve the fallopian tube but it's not infection and it's not hemorrhage.

This patient came with very severe adnexal pain and was not pregnant.
We were asked to look for ovarian torsion.
The patient had a quite normal looking right ovary in gray scale and it had normal color and normal flow, but above and separate from the ovary was an interesting looking structure.
It was filled with simple fluid tubular with an incomplete waist sign.
And on cross section here are those little sort of beads on a string indicating that these are endometrial plica folds.

So what is going on in this situation?
So you can see in this cine clip, here's the tubular structure and it's characteristic little endometrial plica folds and it was separate from the ovary.
This patient had fallopian tube torsion, not ovarian torsion but merely but only torsion of the fallopian tube.
And these images from the laparoscopic procedure show you the twist right here.
And here's the dilated fallopian tube.
A normal ovary and the uterus happen to have some fibroids.

Isolated fallopian tube torsion is an extremely rare situation.
It's usually in premenopausal patients, often in adolescents.
People think that there are a variety of predisposing factors but nobody really knows.
Sometimes there can be a peritoneal mass or cyst that can predispose to it.
The presentation is very similar to ovarian torsion with acute pain and nausea and vomiting and peritoneal signs.
Complications can include necrosis of the tube and often secondarily the ovary for some reason it's more common on the right.
The issue here is that you can see a normal uterus, a normal ovary, and then a dilated fallopian tube displaced out of the pelvis.
Doppler is not necessarily very useful.
More common is that the ovary torses with the tube that is much more common than isolated tubal torsion.

Techniques and Devices Related to Fallopian Tubes and Infertility

And now let's turn to a variety of somewhat newer techniques and devices that have to do with fallopian tubes.
On some ultrasound equipment, one can create something called 3D inversion images, which I'll show you an example of to render the, to show the fallopian tube and appreciate it more easily.
Then one can sometimes use a kind of contrast if you will.
This would be saline with agitated bubbles shaken up in it.
And if you're doing a hysterosonogram, that can be injected into the uterus and if it's somewhat injected robustly, one can see the bubbles going out into the fallopian tubes as a sign of tubal patency.
Others have used actual ultrasound contrast agents and done 3D volumes.
And then the last thing, I'll show you examples of our permanent contraceptive devices which involve the fallopian tubes.

This is an example lent to me by Dr. Serraf.
Here would be a simple gray scale appearance of the fallopian tube.
And this is the inverted 3D image, in which the tube is colored in.
And the background left black to show the dilated fallopian tube.

This is an example of an injection into the uterus of saline with bubbles agitated in it.
You can see them all sort of rumbling around here.
And then if you look out to the side, you see these bright echoes appearing and that's the interstitial portion of the fallopian tube and the bubbles went through it into a portion of the isthmic portion of the tube.
So indicating that at least that one tube was patent.

This is an interesting example.
A patient came for a sonohysterogram predominantly because of menorrhagia, but she also gave us a history of infertility.
When we scanned her. Initially she had a right hydrosalpinx on the left side.
She had the following, a normal looking ovary and in cross-section next to it, not a dilated fallopian tube but just a slightly thickened fallopian tube.
So it measured about one centimeter in thickness too much but not dilated.

We did the hysterosalpingogram and at the end of the procedure went back again to look at the left side and this is now what the left fallopian tube looked like.
Here is a corresponding transverse image and sagittal image and you can see that the tube dilated up.
So we were able to inject enough fluid into that fallopian tube but it was obstructed somewhat on the other end and all of a sudden we created a hydrosalpinx.

Essure Devices for Permanent Contraception

Essure devices are a relatively new form of permanent contraception which is placed in the office through the uterus into the fallopian tubes.
So these devices are supposed to be situated such that a portion is within the interstitial piece of the fallopian tube within the uterus and then about two thirds of it goes out into the extra uterine portion of the fallopian tube.

While in this country we do not use ultrasound primarily to evaluate the results of it.
People get hysterosalpingograms.
Frequently these patients come for ultrasound for other reasons and you may see Essure devices.

So this is an example of the interstitial components of Essure devices in a good location in this patient.
On the left, here's a portion of the Essure device going out into the fallopian tube as it should.
The right Essure device unfortunately however, went right into the myometrium.
Here's a cine clip of that patient and you can see the left Essure device.
You'll see it coming through the interstitial portion right over here and going out the tube and the right device con over here comes down and then curves into the myometrium, never going out the fallopian tube.
So it was malpositioned.

Lookalikes: Other Tubular Structures in the Pelvis

And lastly, I'd like to discuss a variety of other causes of tubular structures in the pelvis, which may or may not be abnormal, but are not fallopian tubes and you may come across them every now and then I'll get somebody who says to me there's a hydrosalpinx and I get an image that looks like this.

There certainly is fluid and there's something that looks a little bit like an incomplete waist sign.
The ovary is off to the side and here in the cine clip you can see it's fluid but it's not a tube.
There's no wall.
The fluid is filling the space here and conforming to the shape of the peritoneal cavity and sort of surrounding the ovary.
And actually this just represents free fluid.
It happens to be more on this side, it looks tubular, but there's really nothing else about it that looks like a tube.
So you shouldn't mistake this for hydrosalpinx.

Here's another patient with a tubular looking fluid filled structure in the pelvis, which you might want to call a dilated fallopian tube, but we turned on the color and all of a sudden the structure fills in with flow.
This is an example of a pelvic varix and this is something that can overlap in appearance with a dilated fallopian tube.
Color will obviously help spectral doppler can help be aware however that sometimes the flow in these varices is so slow that you won't pick it up in color but you actually may see the gray.
The echoes moving in gray scale.

Here's a patient who somebody wanted to tell me had a dilated fallopian tube and indeed does have a somewhat tubular structure with it what looks like an incomplete waist sign.
On the other hand, we found the fallopian tube, the normal fallopian tube with a little paratubal cyst here.
Here's the fallopian tube with the fimbriated end.
And so this cannot be the fallopian tube.
It actually represents another paratubal cyst, just a much larger one.

This patient came with right pelvic pain for rule out pelvic inflammatory disease.
We saw a normal right ovary and next to an cross section, a structure which upon further imaging was tubular but was blind ending and had a slightly thick wall but has actually a gut signature.
We turned the color on and there was flow hyperemia in the wall in this blind ending structure which actually turns out to be the appendix which can often fall into the pelvis and will look tubular, but has a different appearance from a tube from a fallopian tube.
It has a bowel signature.

Another patient with right pelvic pain to rule out pelvic inflammatory disease.
We found in normal uterus and two normal ovaries and lo and behold another tubular structure.
This one however had a bright echo in it with a posterior shadow.
So is this a tube? Is this the appendix with an appendicolith?
This patient turned out to have acute right hydronephrosis and this is the calculus in the distal ureter, which is what we were imaging on ultrasound.

And lastly, this patient with right pelvic pain.
Also to rule out PID has a normal ovary with a follicle, some normal fallopian tube here, fluid and then a large thick walled tubular structure which again has a bowel signature and this one is not the appendix, it's much too big and kept going on and on.
And this is the terminal ileum in this patient who happens to have Crohn's disease and a very thick walled abnormal terminal ileum.

Summary

So in summary, I would urge you to become familiar with the appearance of a normal fallopian tubes and that way you'll be able to appreciate subtle abnormalities.
Remember the variety of signs, the adnexal mass separate from an ovary, the waist sign, incomplete septum sign and cogwheel sign.
Be able to distinguish between acute and chronic disease of the fallopian tube and then to appreciate and understand tubal disease, which is not due to pelvic inflammatory disease.
And please be aware of lookalikes. Thank you. The end.