IS Case 348: Hemorrhagic cyst
2009 URMC Imaging Sciences
Publication Date: 2009-11-09
Patient is a 40-year-old female with right lower quadrant and pelvic pain.
Transvaginal ultrasound shows an avascular 4 cm complex right adnexal cyst with lacelike internal echoes and multiple thin septations.
Ovarian cysts are extremely common occurring in 30-50% of pre-menopausal women and in 6% of post-menopausal women. During the normal menstrual cycle, a dominant follicle ruptures expelling an oocyte and becoming a corpus luteum. There are several small vessels within the cyst wall which can rupture giving rise to a hemorrhagic cyst. These frequently present as severe lower abdominal or pelvic pain. Hemorrhagic cysts can have a variety of appearances. The imaging findings vary depending on the stage of hemorrhage. The most common ultrasound appearances are of a cystic adnexal mass with posterior enhanced through-transmission and reticular "lacelike" or "fishnet" interdigitating septa. Another common appearance is that of a retracting hyperechoic blood clot within an otherwise anechoic cystic mass. Hemorrhagic cysts may rupture leading to hemoperitoneum (echogenic fluid) within the pelvis. If the classic findings are not present, the differential diagnosis includes a solid ovarian mass, ectopic pregnancy, ovarian torsion, or GI disease. Any cyst with papillary projections or nodular septa should be further evaluated with MR. Classic hemorrhagic cysts less than 3 cm do not require follow-up. Any cyst greater than 3 cm or without classic findings requires a follow-up ultrasound in 6-12 weeks to ensure resolution.
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