Magnetic resonance imaging versus computed tomography and ultrasound for the diagnosis of female pelvic pathology

MRI as an alternative to CT after inconclusive ultrasound in subacute/acute abdominal pain in young women: a prospective multicenter noninferiority study

OBJECTIVE

To assess the noninferiority of MRI diagnostic accuracy to CT scan as a second-line examination of acute/subacute abdominopelvic pain in a population of young women after an inconclusive ultrasound (US).

METHODS

This prospective, multicenter non-inferiority study included 18-40-year-old non-pregnant women with non-traumatic acute/subacute abdominal pain. They had an inconclusive US warranting the prescription of an additional CT scan. Within 6 h of the CT, all these women underwent abdomino-pelvic MRI. A retrospective reading of the CT and MR provided a diagnosis using a standardized list. The gold standard diagnosis, based on a 3-month follow-up, was done by a panel of experts. Statistical analysis was conducted to assess the noninferiority of the diagnostic accuracy of MRI compared to that of CT. The noninferiority margin was set at 10%. Inter-observer agreement and diagnostic performance of a conditional imaging strategy were estimated.

RESULTS

133 participants were analyzed (median: 27 years). The most common diagnoses were non-specific pain (30.1%), ovarian cyst rupture (12.8%), and appendicitis (9.7%). MRI demonstrated non-inferiority diagnostic accuracy estimated between 60.9% (81/133) and 88% (117/133) compared to CT, estimated between 64.7% (86/133) and 83.5% (111/133). The conditional imaging strategy (MRI, followed by CT when the MRI was normal) had a diagnostic accuracy of 91%.

CONCLUSION

MRI diagnostic performances are not inferior to CT for acute abdominal pain in women aged 18-40. A conditional imaging strategy based on MRI would give an accuracy of 91% and might be considered a second-line imaging modality in that context.

KEY POINTS

Question Can MRI serve as an alternative to CT as a second-line imaging modality for acute abdominopelvic pain in young women (18-40) after an inconclusive ultrasound? Findings MRI accuracy after inconclusive US ranged from 60.9 to 88%. A conditional strategy (MRI first, CT if normal) reached 91% accuracy, avoiding 59% of CTs. Clinical relevance MRI is not inferior to CT for diagnosing uncategorized causes of acute abdomino-pelvic pain in young non-pregnant women. A conditional imaging strategy based on MRI as a second-line imaging modality would give an accuracy of 91%.

Rapid MRI Abdomen for Assessment of Clinically Suspected Acute Appendicitis in the General Adult Population: a Systematic Review

OBJECTIVES

To perform a systematic review on the use of magnetic resonance imaging (MRI) of the abdomen to evaluate clinically suspected appendicitis in the general adult population. We examined the diagnostic accuracy, the reported trends of MRI use, and the factors that affect the utility of MRI abdomen, including study duration and cost-benefits.

METHODS

We conducted a systematic literature search on PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library databases. We enrolled primary studies investigating the use of MRI in diagnosing appendicitis in the general adult population, excluding studies that predominantly reported on populations not representative of typical adult appendicitis presentations, such as those focusing on paediatric or pregnant populations.

RESULTS

Twenty-seven eligible primary studies and 6 secondary studies were included, totaling 2,044 patients from eight countries. The sensitivity and specificity of MRI for diagnosing appendicitis were 96% (95% CI: 93-97%) and 93% (95% CI: 80-98%), respectively. MRI can identify complicated appendicitis and accurately propose alternative diagnoses. The duration of MRI protocols in each primary study ranged between 2.26 and 30 minutes, and only one study used intravenous contrast agents in addition to the non-contrast sequences. Decision analysis suggests significant benefits for replacing computed tomography (CT) with MRI and a potential for cost reduction. Reported trends in MRI usage showed minimal utilisation in diagnostic settings even when MRI was available.

CONCLUSIONS

MRI accurately diagnoses appendicitis in the general adult population and improves the identification of complicated appendicitis or alternative diagnoses compared to other modalities using a single, rapid investigation.

The Acute Female Nongravid Pelvis: A Review of Appropriate Clinical Applications of Sonography, Computed Tomography, and Magnetic Resonance Imaging

Objective:

The objective of this literature review was to provide a summary of the primary concerns in evaluating ovarian cysts and compare the diagnostic roles of each imaging technique, in an emergent setting.

Materials and Methods:

A literature review of the imaging evaluation of functional ovarian cysts, emergent complications, and relevant case studies was performed using peer-reviewed articles. The literature search was conducted using PubMed, The Wiley Online Library, and Google Scholar search engines.

Results:

Sonography, computed tomography (CT), and magnetic resonance imaging (MRI) demonstrate comparable accuracy in the diagnosis of functional ovarian cysts and ovarian torsion. While sonography is the preferred method of imaging the female pelvis, CT and MRI demonstrate similar diagnostic capabilities.

Conclusion:

Functional ovarian cyst rupture/hemorrhage and ovarian torsion can be accurately demonstrated using sonography, CT, and MRI.

Abdominal Pain in the Emergency Department: How to Select the Correct Imaging for Diagnosis

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Virtual Journal Club Beyond the Pandemic: An Enduring and Fluid Educational Forum

OBJECTIVE

Since its inception, journal club has been a cornerstone to the life-long process of medical education. The virtual journal club (VJC), initiated as a robust solution to many educational challenges encountered during COVID-19 pandemic-related distance learning, provides an enduring and fluid forum for multilevel teaching and learning.

MATERIALS AND METHODS

In this manuscript we share our institutions' reasoning and methods to implement a VJC for multi-level learners. A standardized format applicable to all VJC sessions was adopted to ensure reproducibility from presenter to presenter. Sessions were held via video conference platforms. Pedagogy regularly emphasized in undergraduate medical education was adopted. Informal assessment of each session's strengths and areas for improvement was performed.

RESULTS

A total of 30 sessions were held prior to manuscript submission, including discussion of 36 refereed journal articles from March 26, 2020, to April 20, 2021. The virtual journal club was very well received by all participants. The medical students and residents found the information current and engaging. The fellows stated that the journal club strengthened their knowledge base and enhanced communication and teaching skills. The attendings learned from its encouraged frank discussion of differing practice patterns. The format of these sessions offers an ideal setting to teach medical students and residents how to evaluate and employ evidence-based medicine and meets multiple LCME and ACGME requirements.

CONCLUSIONS

This VJC forum allows for development of essential nonclinical skills including lifelong active learning and analysis, peer collaboration, and technology adaptation and usage.