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DR. PRADOSH KUMAR SARANGI
HYSTEROSALPINGOGRAPHY
UNDER GUIDANCE OF
DR JAYASHREE MOHANTY
DR SASMITA PARIDA
DR B M SWAIN
DR K...
HYSTEROSALPINGOGRAPHY
Hysterosalpingography is the radiographic
evaluation of uterus and fallopian tubes under
fluoroscopi...
INDICATION
1. Infertility (main role)
2. Recurrent spontaneous abortions
3. Congenital anomalies of uterus
4. Postoperativ...
CONTRAINDICATION
• Suspected pregnancy
• Acute pelvic infection
• Active vaginal bleeding
• Recent dilation and curettage
...
PATIENT PREPARATION
• Done in first half of menstrual cycle in
proliferative phase between 8th to 12th day
• Patient to av...
PROCEDURE
• Informed consent is taken
• Antispasmodic (im drotin) given before procedure.
• Patient is asked to empty blad...
PROCEDURE ....
• Tenaculm is used to hold anterior lip of cervix .
• Speculum is removed & Patient is placed in slight
tre...
COMPLICATION
• Pain (because of dilatation of uterus , spillage into
peritonium).
• Infection (pelvic).
• Bleeding.
• Vasc...
HISTORY OF HSG
• First report on HSG using oil soluble contrast
(collargel) published by Carey in 1914.
• Collargel – sign...
HISTORY....
• Rubin insufflated oxygen (later carbon dioxide)
under pressure through the cervical canal into
the uterine c...
• Lipiodol was gradually replaced by water
soluble contrast media for several reasons
LIPIODOL is 40% iodine in poppy seed...
CONTRAST MEDIA
LIPID SOLUBLE CONTRAST
(lipiodol)
• Sharp image
• Minimal pain
• Delayed absorption
• Risk of lipogranuloma...
tenaculum
Hegar dilator
Speculum
leech wilkinson
cannula
Sponge holder
3-Jan-16 13
Different types of cannula used
1. leech wilkinson cannula
2. acorn tip metallic cannula
3.cervical vaccum cup
4. balloon ...
WHICH ONE IS BETTER??
• Cervical vacuum cup vs metal cannula:
Shorter length of time
less fluoroscopic time
small amount o...
BALLOON CATHETER VS METAL
CANNULA
Less fluoroscopic time
Small amount of contrast
Less pain
Easier for physician to use
Go...
• Balloon catheter obscures lower uterine
segment. Need to be deflated to visualise
lower segment
• Balloon catheter bette...
Cervical vacuum cup cannula
3-Jan-16 18
Acorn tip metal cannula
3-Jan-16 19
3-Jan-16 20
BALLOON CATHETER
NORMAL HSG
• The uterine cavity is shown
during HSG as a triangular
contrast-filled structure,
with its base on top and
th...
At least 4 spot films taken
4.Peritoneal
spillage
2. Uterus fully
distended
1.Early filling
phase
3.Tubal filling
phase
NO...
DETECTABLE PATHOLOGY
UTERINE
1. Uterine anomaly
2. Fibroid ( submucosal)
3. Adenomyosis
4. Endometrial polyp
5. Intrauteri...
NON PATHOLOGIC FINDINGS
• Air bubble- round, often multiple, welldefined
mobile filling defect ,usually displaced to
fallo...
Luminal filling defects
• Common finding.
• Includes :
Air bubbles
Uterine folds
Synechiae
endometrial polyp
submucosal fi...
Spot radiograph shows air bubbles (arrow) in the left
side of the uterus.
AIR BUBBLE
3-Jan-16 26
Filling defects on consecutive images at the uterine fundus, that disappear
progressively after the administration of cont...
HSG spot radiograph demonstrates uterine folds (arrows) as linear
filling defects that parallel the longitudinal axis of t...
PROMINENT CERVICAL GLANDS
3-Jan-16 29
Spot radiograph shows the uterine incision from a cesarean section (arrows) in the
typical location (i.e., oriented transv...
UTERINE ANOMALIES
class anomaly
i Partial / complete agenesis
ii Unicornuate
iii Didelphys
iv Bicornuate
V Septate
Vi Arcu...
3-Jan-16 32
 Diagnosis: unicornuate uterus.
 Description: one cornua , one tube , one spillage.
3-Jan-16 33
UNICORNUATE UTERUS
Single right uterine horn with single right fallopian
tube. Right side spillage seen
3-Jan-16 34
UTERUS DIDELPHYS
2 Uterine cavities, 2 cervical canals, 2 vagina..
(nonfusion of the two Müllerian ducts.)
3-Jan-16 35
VAG...
UTERUS DIDELPHYS
3-Jan-16 36
BICORNUATE UNICOLLIS
2 uterine cavities, 1 cervical canal
Incomplete fusion of the cephalad extent of the uterovaginal hor...
BICORNUATE UNICOLLIS UTERUS
3-Jan-16 38
BICORNUATE BICOLLIS
3-Jan-16 39
Spot radiograph shows two markedly splayed uterine horns.
BICORNUATE UTERUS
3-Jan-16 40
BICORNUATE UNICOLLIS
3-Jan-16 41
> 100
degree
2 uterus
2 cervix
2 vagina
2 uterus
2 cervix
1 vagina
3-Jan-16 42
DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed ...
ARCUATE UTERUS
Depression of uterine fundus
3-Jan-16 44
SEPTATE UTERUS: PARTIAL AND
COMPLETE
There is incomplete resorption of the final fibrous
septum between the two uterine ho...
SEPTATE UTERUS
3-Jan-16 46
slight separation (forming acute angle).
SEPTATE UTERUS
3-Jan-16 47
Bicornuate and Septate Uteri
• Bicornuate:
– Fundus indented
– Cavities widely
separated( > 100 degree)
– Partial fusion o...
ADENOMYOSIS
Irregular outline, multiple diverticulum
(arrows)
3-Jan-16 49
FIBROID UTERUS
Multiple filling defects
3-Jan-16 50
RIGHT SUBMUCOSAL MYOMA
3-Jan-16 51
SALPINGITIS ISTHMICA NODOSA
• Out pouchings of isthmus
• Unilateral or bilateral
• Unknown cause
• Associated with inferti...
SALPINGITIS ISTHMIC NODOSUM (SIN)
small outpouchings or diverticula from the isthmic
portion of the fallopian tubes. SIN c...
LEFT SALPINGITIS ISTHIMICA NODOSUM
Multiple outpouchings from isthmus ( arrow)
3-Jan-16 54
RIGHT HYDROSALPINX
Steep right oblique spot radiograph shows dilatation of the ampullary portion of
the right fallopian tu...
BILATERAL HYDROSALPINX
3-Jan-16 56
TUBAL POLYP
small filling defect (arrow) in the proximal left
fallopian tube, a finding that typically represents a
tubal ...
TUBAL POLYP . (FILLING DEFECT)
3-Jan-16 58
Dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a
hydrosalpinx. No contr...
Cutoff of contrast material in the isthmic portions of both fallopian tubes, with
bulbous dilatation of the distal aspects...
A round collection of contrast material adjacent to the left
fallopian tube, a finding that suggests peritubal adhesions. ...
SYNECHIAE
• Intra uterine adhesions
• Post curettage and infection
• Linear filling defect
• Arising from one of the uteri...
Central oval filling defect within the uterus
SYNECHIAE
3-Jan-16 63
SYNECHIAE
Multiple irregular filling defects in uterine
cavity
3-Jan-16 64
Right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left
fallopian tube opacifies to the...
LEFT CORNUAL SPASM
3-Jan-16 66
B/L FALLOPIAN TUBE LIGATION
No peritoneal spillage of contrast
3-Jan-16 67
VASCULAR INTRAVASATION
3-Jan-16 68
Irreversible tubal occlusion with a microinsert. Scout radiograph
obtained prior to the instillation of contrast material ...
Radiograph obtained after instillation shows no contrast
material filling of the fallopian tube beyond the microinsert, a
...
HSG FINDINDS IN GENITAL
TUBERCULOSIS
FALLOPIAN TUBES UTERUS
 SPECIFIC
Beaded tube
Golf club tube
Pipestem tube
Cobbleston...
TUFTED TUBE
Multiple small diverticular like appearance surrounding
the ampulla produced by caseous ulceration gives the
t...
TB SIN-like
Penetration of contrast medium between the mucosal folds
produces small diverticular-like outpouchings with a ...
cotton-wool plug appearance
Distribution of contrast medium in a reticular pattern
producing a " cotton-wool plug" appeara...
BEADED TUBE
Multiple constrictions along the fallopian tube giving rise to
a " beaded" appearance [arrows]
3-Jan-16 75
GOLF CLUB TUBE
Sacculation of both tubes in distal portion with an
associated hydrosalpinx giving a Golf club-like appeara...
PIPE STEM APPEARANCE
Absence of normal tortuosity and a curved or straight pipe like
appearance show fibrotic stage of tub...
FLORAL APPEARANCE
Twisted hydrosalpinx resembles a floral
appearance of left side tube (arrow).
3-Jan-16 78
LEOPARD SKIN APPEARANCE
Multiple rounded filling defects following intraluminal granuloma
formations within the hydrosalpi...
COBBLE STONE APPEARANCE
Intraluminal scarring of the tube gives rises a cobblestone
like appearance which is an effective ...
CORK SCREW APPREANCE
Vertically fixed tubes secondary to dense peritubal
adhesions. Dense connective tissue causes the lac...
PERITUBAL HALO
Thickening of the tubal walls due to peritubal adhesions
(arrows) represents a cloudy sign on hysterosalpin...
TOBACCO POUCH APPREANCE
Terminal hydrosalpinx with the conical narrowing is seen in the
right tube (arrow). Eversion of th...
A.Uterine cavity is normal in shape and size. Terminal sacculation are seen
in both tubes. B. Irregularity, multiple filli...
A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an
asymmetric intrauterine obliteration, resembling ...
T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS
T-shaped configuration in two different patients. A. " T-shaped"
tuberculo...
TRIFOLIATE SHAPED UTERUS
Synechiae formation at the uterine borders and partial
obliteration in the fundus produce a trifo...
DIAGNOSTIC ACCURACY
(Hsg vs laparoscopy)
• Hsg-minimally invasive
-superior to laparoscopy for detecting
intrinsic tubal a...
3-Jan-16 89
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Hysterosalpingography

  1. 1. DR. PRADOSH KUMAR SARANGI HYSTEROSALPINGOGRAPHY UNDER GUIDANCE OF DR JAYASHREE MOHANTY DR SASMITA PARIDA DR B M SWAIN DR KALYANI PARIDA 3-Jan-161
  2. 2. HYSTEROSALPINGOGRAPHY Hysterosalpingography is the radiographic evaluation of uterus and fallopian tubes under fluoroscopic guidance. 3-Jan-16 2
  3. 3. INDICATION 1. Infertility (main role) 2. Recurrent spontaneous abortions 3. Congenital anomalies of uterus 4. Postoperative evaluation following (a)tubal ligation (b) reversal of tubal ligation 5. Suspected case of genital tuberculosis 6. To prove tubal occlusion after insertion of transcervival sterilization microinsert (essure) HSG also has a potential therapeutic role in increasing the probability of pregnancy ( especially if oil soluble contrast –lipiodol is used)3-Jan-16 3
  4. 4. CONTRAINDICATION • Suspected pregnancy • Acute pelvic infection • Active vaginal bleeding • Recent dilation and curettage • Immediate pre and post menstrual phase • Tubal or uterine surgery within last 6 wks • Contrast sensitivity 3-Jan-16 4
  5. 5. PATIENT PREPARATION • Done in first half of menstrual cycle in proliferative phase between 8th to 12th day • Patient to avoid unprotected sexual intercourse from the date of her period until investigation is over to avoid possible risk of pregnancy • If periods are irregular , do urine b- hcg test to rule out pregnancy • Exclude active pelvic infection • Prophylactic antibiotics not routinely recommended (considered in case of bacterial endocarditis) 3-Jan-16 5
  6. 6. PROCEDURE • Informed consent is taken • Antispasmodic (im drotin) given before procedure. • Patient is asked to empty bladder immediately before procedure • Scot film may be taken. • Patint is placed in lithotomy position • The perineum is cleaned with antiseptic solution (Betadine)and draped with sterile towel. The cervix is localized and cleansed with povidone-iodine solution. A speculum is inserted into the vagina. Cervix is cannulated with any of available cannulas which is made air free before administration of contrast 3-Jan-16 6
  7. 7. PROCEDURE .... • Tenaculm is used to hold anterior lip of cervix . • Speculum is removed & Patient is placed in slight trendelenburg position and contrast is slowly given • 3 ml contrast to fill uterine cavity and another 3 ml to fill tube. ( up to 10 ml) • 4 spot films are taken • Additional oblique views may be taken for optimal visualisation of pelvic pathology and tortuous fallopian tubes( to see retroverted or anteverted) • After end of the procedure , antibiotic course is given and patient is informed about vaginal spotting for 1-2 days 3-Jan-16 7
  8. 8. COMPLICATION • Pain (because of dilatation of uterus , spillage into peritonium). • Infection (pelvic). • Bleeding. • Vascular or lymphatic Intravasation • Vasovagal episode. • Pregnancy irradiation. • Allergic reaction (to iodinated contrast media). • Uterine perforation 3-Jan-16 8
  9. 9. HISTORY OF HSG • First report on HSG using oil soluble contrast (collargel) published by Carey in 1914. • Collargel – significant tissue damage and painful • Because of these serious adverse events, its use was abandoned and a tubal insufflation test was introduced by Rubin in 1920 (Rubin, 1920) 3-Jan-16 9
  10. 10. HISTORY.... • Rubin insufflated oxygen (later carbon dioxide) under pressure through the cervical canal into the uterine cavity. Tubal patency was determined by presence of air under the diaphragm on X-ray, by auscultation of air flow into the abdomen or a drop in pressure during insufflation • Heuser was the first to report on the use of lipiodol in HSGs (Heuser, 1925) • Lipiodol- oil soluble, low viscosity, less toxic, became widely accepted 3-Jan-16 10
  11. 11. • Lipiodol was gradually replaced by water soluble contrast media for several reasons LIPIODOL is 40% iodine in poppy seed oil Manufactured by guerbert ,france WHY WATER SOLUBLE CONTRAST MEDIA ARE PREFERRED ? 3-Jan-16 11
  12. 12. CONTRAST MEDIA LIPID SOLUBLE CONTRAST (lipiodol) • Sharp image • Minimal pain • Delayed absorption • Risk of lipogranuloma formatation in case of tubal block or hydrosalpinx • Intravasation of contrast and possible risk of oil embolism • Need of delayed film • Pregnancy rate doubled • Less often used WATER SOLUBLE CONTRAST (iohexol-omnipaque,meglumine diatrizoate-urograffin • Ampullary rugae clearly visualised • Gets absorbed within hours, does not leave residue • Granuloma formation rare • Pain persists after procedure • Prompt demonstration of tubal patency, delayed film not needed. • Widely used and preferred 3-Jan-16 12
  13. 13. tenaculum Hegar dilator Speculum leech wilkinson cannula Sponge holder 3-Jan-16 13
  14. 14. Different types of cannula used 1. leech wilkinson cannula 2. acorn tip metallic cannula 3.cervical vaccum cup 4. balloon catheter or pediatric foley’s catheter 6F 3-Jan-16 14
  15. 15. WHICH ONE IS BETTER?? • Cervical vacuum cup vs metal cannula: Shorter length of time less fluoroscopic time small amount of contrast needed less pain ( no need to grasp cervix) Easier for physician to use Uterus cant be easily manipulated Need to reapply cannula Superior to metal cannula Cervical vacuum cup 3-Jan-16 15 Cohen et al (British Journal of Obstetrics and Gynaecology October 2001, Vol. 108, pp. 1031–1035)
  16. 16. BALLOON CATHETER VS METAL CANNULA Less fluoroscopic time Small amount of contrast Less pain Easier for physician to use Good seal at cervix Single use/disposable(costly) Superior to metal cannula 3-Jan-16 16 BALLOON CATHETER Tur-kaspa et al (Human Reproduction vol.13 no.1 pp.75–77, 1998)
  17. 17. • Balloon catheter obscures lower uterine segment. Need to be deflated to visualise lower segment • Balloon catheter better tolerated over cervical cup 3-Jan-16 17
  18. 18. Cervical vacuum cup cannula 3-Jan-16 18
  19. 19. Acorn tip metal cannula 3-Jan-16 19
  20. 20. 3-Jan-16 20 BALLOON CATHETER
  21. 21. NORMAL HSG • The uterine cavity is shown during HSG as a triangular contrast-filled structure, with its base on top and the apex caudally (inverted triangle) and the uterine fundus on top, which can be flattened, concave or slightly convex . -free spillage of the contrast to the peritoneum noted 3-Jan-16 21
  22. 22. At least 4 spot films taken 4.Peritoneal spillage 2. Uterus fully distended 1.Early filling phase 3.Tubal filling phase NORMAL HSG 3-Jan-16 22
  23. 23. DETECTABLE PATHOLOGY UTERINE 1. Uterine anomaly 2. Fibroid ( submucosal) 3. Adenomyosis 4. Endometrial polyp 5. Intrauterine adhesions/synaechiae 6. Endometrial TB 7. Cervical incompetence TUBAL 1. tubal block 2. Tubal spasm 3. Tubal polyp 4. Hydrosalpinx 5. Salpingitis isthmic nodosum (SIN) 6. Peritubal adhesions 7. TB salpingitis 3-Jan-16 23
  24. 24. NON PATHOLOGIC FINDINGS • Air bubble- round, often multiple, welldefined mobile filling defect ,usually displaced to fallopian tubes if additional contrasts given • Normal myometrial folds-longitudinal folds with parallel orientation to uterine cavity • Prominent cervical glands-tubular structure with their origin in both cervical walls • Previous caeserean section scar 3-Jan-16 24
  25. 25. Luminal filling defects • Common finding. • Includes : Air bubbles Uterine folds Synechiae endometrial polyp submucosal fibroid 3-Jan-16 25
  26. 26. Spot radiograph shows air bubbles (arrow) in the left side of the uterus. AIR BUBBLE 3-Jan-16 26
  27. 27. Filling defects on consecutive images at the uterine fundus, that disappear progressively after the administration of contrast, compatible with air bubbles. 3-Jan-16 27 DISAPPEARS
  28. 28. HSG spot radiograph demonstrates uterine folds (arrows) as linear filling defects that parallel the longitudinal axis of the uterus. Uterine folds are normal findings that are occasionally seen at HSG. UTERINE FOLDS 3-Jan-16 28
  29. 29. PROMINENT CERVICAL GLANDS 3-Jan-16 29
  30. 30. Spot radiograph shows the uterine incision from a cesarean section (arrows) in the typical location (i.e., oriented transverse in the lower uterine segment in the region of the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum. CESAREAN SECTION SCAR 3-Jan-16 30
  31. 31. UTERINE ANOMALIES class anomaly i Partial / complete agenesis ii Unicornuate iii Didelphys iv Bicornuate V Septate Vi Arcuate vii DES-associated anomalies 3-Jan-16 31 AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE
  32. 32. 3-Jan-16 32
  33. 33.  Diagnosis: unicornuate uterus.  Description: one cornua , one tube , one spillage. 3-Jan-16 33
  34. 34. UNICORNUATE UTERUS Single right uterine horn with single right fallopian tube. Right side spillage seen 3-Jan-16 34
  35. 35. UTERUS DIDELPHYS 2 Uterine cavities, 2 cervical canals, 2 vagina.. (nonfusion of the two Müllerian ducts.) 3-Jan-16 35 VAGINAL SEPTUM
  36. 36. UTERUS DIDELPHYS 3-Jan-16 36
  37. 37. BICORNUATE UNICOLLIS 2 uterine cavities, 1 cervical canal Incomplete fusion of the cephalad extent of the uterovaginal horns with resorption of the uterovaginal septum. 3-Jan-16 37 1 CERVIX
  38. 38. BICORNUATE UNICOLLIS UTERUS 3-Jan-16 38
  39. 39. BICORNUATE BICOLLIS 3-Jan-16 39
  40. 40. Spot radiograph shows two markedly splayed uterine horns. BICORNUATE UTERUS 3-Jan-16 40
  41. 41. BICORNUATE UNICOLLIS 3-Jan-16 41 > 100 degree
  42. 42. 2 uterus 2 cervix 2 vagina 2 uterus 2 cervix 1 vagina 3-Jan-16 42
  43. 43. DES-related uterine anomaly. Hysterosalpingogram demonstrates a hypoplastic T-shaped uterus. The patient had been exposed to DES while in utero.3-Jan-16 43
  44. 44. ARCUATE UTERUS Depression of uterine fundus 3-Jan-16 44
  45. 45. SEPTATE UTERUS: PARTIAL AND COMPLETE There is incomplete resorption of the final fibrous septum between the two uterine horns. SEPTUM PARTIAL COMPLETE 3-Jan-16 45
  46. 46. SEPTATE UTERUS 3-Jan-16 46
  47. 47. slight separation (forming acute angle). SEPTATE UTERUS 3-Jan-16 47
  48. 48. Bicornuate and Septate Uteri • Bicornuate: – Fundus indented – Cavities widely separated( > 100 degree) – Partial fusion of mullerian ducts • Septate: – Normal external surface – Cavities are close together – Defect in canalization or resorption of midline septum between mullerian ducts. HSG cant differentiate these two. Definite diagnosis by MRI Intervening cleft > 1 cm & intercornual distance > 5cm in bicornuate uterus 3-Jan-16 48
  49. 49. ADENOMYOSIS Irregular outline, multiple diverticulum (arrows) 3-Jan-16 49
  50. 50. FIBROID UTERUS Multiple filling defects 3-Jan-16 50
  51. 51. RIGHT SUBMUCOSAL MYOMA 3-Jan-16 51
  52. 52. SALPINGITIS ISTHMICA NODOSA • Out pouchings of isthmus • Unilateral or bilateral • Unknown cause • Associated with infertility, PID and ectopic pregnancy 3-Jan-16 52
  53. 53. SALPINGITIS ISTHMIC NODOSUM (SIN) small outpouchings or diverticula from the isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral. 3-Jan-16 53
  54. 54. LEFT SALPINGITIS ISTHIMICA NODOSUM Multiple outpouchings from isthmus ( arrow) 3-Jan-16 54
  55. 55. RIGHT HYDROSALPINX Steep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes 3-Jan-16 55
  56. 56. BILATERAL HYDROSALPINX 3-Jan-16 56
  57. 57. TUBAL POLYP small filling defect (arrow) in the proximal left fallopian tube, a finding that typically represents a tubal polyp 3-Jan-16 57
  58. 58. TUBAL POLYP . (FILLING DEFECT) 3-Jan-16 58
  59. 59. Dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation. LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION 3-Jan-16 59
  60. 60. Cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation). TUBAL LIGATION 3-Jan-16 60
  61. 61. A round collection of contrast material adjacent to the left fallopian tube, a finding that suggests peritubal adhesions. Note the free contrast material spillage on the right side. LEFT PERITUBAL ADHESION 3-Jan-16 61
  62. 62. SYNECHIAE • Intra uterine adhesions • Post curettage and infection • Linear filling defect • Arising from one of the uterine walls • Multiple+infertility= Asherman syndrome 3-Jan-16 62
  63. 63. Central oval filling defect within the uterus SYNECHIAE 3-Jan-16 63
  64. 64. SYNECHIAE Multiple irregular filling defects in uterine cavity 3-Jan-16 64
  65. 65. Right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image CORNUAL SPASM 3-Jan-16 65
  66. 66. LEFT CORNUAL SPASM 3-Jan-16 66
  67. 67. B/L FALLOPIAN TUBE LIGATION No peritoneal spillage of contrast 3-Jan-16 67
  68. 68. VASCULAR INTRAVASATION 3-Jan-16 68
  69. 69. Irreversible tubal occlusion with a microinsert. Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube. SCOUT FILM 3-Jan-16 69
  70. 70. Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion. 3-Jan-16 70
  71. 71. HSG FINDINDS IN GENITAL TUBERCULOSIS FALLOPIAN TUBES UTERUS  SPECIFIC Beaded tube Golf club tube Pipestem tube Cobblestone tube Leopard skin tube  NON SPECIFIC Hydrosalpinx Mucosal thickening Peritubal adhesion  SPECIFIC T shaped uterus Pseudounicornuate uterus Trifoliate uterus  NONSPECIFIC endometritis Syneciae distortion of uterine contour Venous, lymphatic intravasation 3-Jan-1671
  72. 72. TUFTED TUBE Multiple small diverticular like appearance surrounding the ampulla produced by caseous ulceration gives the tubal outline a Rosette-like appearance 3-Jan-16 72
  73. 73. TB SIN-like Penetration of contrast medium between the mucosal folds produces small diverticular-like outpouchings with a bizarre pattern. Entire of both tube involved (arrows). 3-Jan-16 73
  74. 74. cotton-wool plug appearance Distribution of contrast medium in a reticular pattern producing a " cotton-wool plug" appearance [arrow] 3-Jan-16 74
  75. 75. BEADED TUBE Multiple constrictions along the fallopian tube giving rise to a " beaded" appearance [arrows] 3-Jan-16 75
  76. 76. GOLF CLUB TUBE Sacculation of both tubes in distal portion with an associated hydrosalpinx giving a Golf club-like appearance (arrows). 3-Jan-16 76
  77. 77. PIPE STEM APPEARANCE Absence of normal tortuosity and a curved or straight pipe like appearance show fibrotic stage of tuberculous salpingitis. Irregular contour of the uterine cavity with diminished capacity in the fundual portion resembling a septate uterus. 3-Jan-16 77
  78. 78. FLORAL APPEARANCE Twisted hydrosalpinx resembles a floral appearance of left side tube (arrow). 3-Jan-16 78
  79. 79. LEOPARD SKIN APPEARANCE Multiple rounded filling defects following intraluminal granuloma formations within the hydrosalpinx, resembling a " leopard skin" appearance [arrows] 3-Jan-16 79
  80. 80. COBBLE STONE APPEARANCE Intraluminal scarring of the tube gives rises a cobblestone like appearance which is an effective radiographic sign of intraluminal adhesions 3-Jan-16 80
  81. 81. CORK SCREW APPREANCE Vertically fixed tubes secondary to dense peritubal adhesions. Dense connective tissue causes the lack of tubal mobility. The hyperconvulated right tube and manifests a " cork screw" like appearance [arrows]3-Jan-16 81
  82. 82. PERITUBAL HALO Thickening of the tubal walls due to peritubal adhesions (arrows) represents a cloudy sign on hysterosalpingograms. This finding is a non-specific feature of tubal tuberculosis.3-Jan-16 82
  83. 83. TOBACCO POUCH APPREANCE Terminal hydrosalpinx with the conical narrowing is seen in the right tube (arrow). Eversion of the fimbria secondary to adhesions, with a patent orifice produces the tobacco pouch appearance in the left terminal. 3-Jan-16 83
  84. 84. A.Uterine cavity is normal in shape and size. Terminal sacculation are seen in both tubes. B. Irregularity, multiple filling defects and obliteration of right ostium secondary to extensive synechiae formation in this site. Obstruction of left tube is also seen. A B 3-Jan-16 84 INTRAUTERINE ADHESION AND DISTORTION
  85. 85. A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an asymmetric intrauterine obliteration, resembling a unicornuate uterus. the irregular contour and vertical orientation of long axis. B. True unicornuate uterus. the smooth contour, more horizontal orientation of long axis and normal ipsilateral fallopian tube. 3-Jan-16 85
  86. 86. T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS T-shaped configuration in two different patients. A. " T-shaped" tuberculosis uterus. Irregular contour of the uterine cavity with diminished capacity resembling a T-shaped uterus. Both tubes are obstructed from isthmic portion.B. T-shaped uterus due to DES exposure. Narrow endocervical canal and small uterine cavity. Note both tubes are normal.3-Jan-16 86
  87. 87. TRIFOLIATE SHAPED UTERUS Synechiae formation at the uterine borders and partial obliteration in the fundus produce a trifoliate like appearance. Both tubes are obstructed in the isthmic portion 3-Jan-16 87
  88. 88. DIAGNOSTIC ACCURACY (Hsg vs laparoscopy) • Hsg-minimally invasive -superior to laparoscopy for detecting intrinsic tubal and uterine pathology. - false negative rate due to undected peritubal adhesion,incomplete filling of a dilated hydrosalpinx - false positive rate due to tubal spasm, inadequate contrast injection  both are complementary methods in evaluation of infertility 3-Jan-16 88
  89. 89. 3-Jan-16 89
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everything you want to know about HSG in a concise manner.

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