0:01

Okay, so let's look at another case

0:03

of endometriosis and specifically

0:05

we're going to look at rectosigmoid

0:07

involvement in this case, but I wanted

0:09

to show you a few more things as well.

0:11

So remember our approach to

0:13

endometriosis and research pattern.

0:16

So in the last case, we looked first

0:18

at the position of the ovaries.

0:20

So here we've got an axial T2

0:22

weighted sequence, and we can see the

0:24

left ovary that's got a cyst in it.

0:28

And as we scroll down, we can see something

0:30

that looks like a right ovary here, but

0:33

note the position of that right ovary.

0:36

So it's definitely not lateral or adjacent

0:40

to the external or common iliac vessels,

0:43

but it's definitely more inferior to

0:45

its normal location and closer to the midline.

0:47

It's being drawn in or dragged

0:49

in by some other process here.

0:51

So that position of that ovary is not normal.

0:54

All right.

0:54

So we've noted that abnormal position

0:57

of the right ovary, and then the left

1:00

ovary obviously looks enlarged, and we've

1:02

got some T2 shading here, which on T1

1:06

corresponds to some high signal here.

1:10

And this is a nice case

1:11

as well to show you that.

1:13

candle wax phenomenon that we talked about.

1:15

So look at the outside of this left ovary.

1:18

Look at these little cystic structures

1:20

that are next to the ovary, and some

1:23

of them have some high T1 signal.

1:25

So you would be able to see this on ultrasounds.

1:28

We've got an endometrioma with some little

1:30

cysts around it that are hemorrhagic.

1:32

And that's a really nice example

1:34

of the candle phenomenon.

1:37

Okay.

1:38

And then if we look at the torus uterinus.

1:41

So remember, that's along the posterior wall of

1:45

the uterus and kind of anterior to the rectum.

1:48

We've got this ill-defined area of

1:51

pretty low T2 signal, and there's

1:54

an area of kind of high T2 signal.

1:57

And if we look at the T1-weighted

1:58

images in the same area, we've got

2:00

these little dots of high T1 signal.

2:02

So this is definitely a

2:04

manifestation of endometriosis.

2:06

So this is an implant, an area of fibrosis,

2:09

scarring, and probably repeated bleeding.

2:11

So if you're a breast imager, you would

2:14

call this architectural distortion.

2:16

So this is kind of a similar phenomenon

2:18

where the scarring is causing pulling or

2:21

retraction of the adjacent structures.

2:24

You can see the rectal wall here

2:25

is kind of tethered anteriorly.

2:27

So it's pulling in all the

2:29

adjacent structures, the right

2:30

ovary as well as being pulled in.

2:32

And then if we look at the sagittal images, this

2:35

is kind of nice because when we see the torus

2:39

veneratus thickening, this is the area where

2:40

the abnormality would be on the sagittal images.

2:42

And then look what's happened

2:44

to the anterior rectal wall.

2:45

We've got this low T2 signal,

2:48

submucosal lesion here.

2:51

And.

2:52

Hopefully you can imagine that it

2:54

looks like the cap of a mushroom.

2:56

That's what the mushroom cap sign looks like.

2:58

So if you were to do a barium enema in this

3:00

patient, you would see opacification of

3:03

the rectum, and then you'd see this smooth

3:06

semicircular filling defect because of this

3:08

rectosigmoid involvement by endometriosis.

3:11

So, again along the posterior

3:13

margin of the uterus, notice how

3:15

we've got a linear configuration.

3:18

It's not nice and smooth.

3:19

We've got some thickening, a triangular

3:21

shape there, and that corresponds

3:23

to thickening of the torus uteritis.

3:25

So this patient actually has several

3:27

manifestations of endometriosis

3:29

that we've talked about already.

3:31

And then she's also got an IUD here that

3:34

we can see nicely with some susceptibility

3:36

artifact on the gradient echo images.