Case contributed by Ammar Haouimi
Diagnosis almost certain


Right lower abdominal pain with fever and leukocytosis, to rule out appendicitis. History of four cesarean sections.

Patient Data

Age: 40 years
Gender: Female

There is a thick-walled cystic tubular structure with thick fluid content and fluid-fluid level.

Normal appearance of the right ovary as well as the appendix (not shown).


The MRI sequences demonstrate a right cystic mass posterolateral to the uterus with a thick enhanced wall with fluid-fluid content that shows restricted diffusion. Marked surrounding inflammatory changes extending to the left pelvic region, minimal peritoneal effusion with thickening and enhancement of the adjacent peritoneal reflections suggestive of pelvic peritonitis.

Elongated uterus adherent to the surgical scar (history of previous cesarean sections).

The left ovary shows small follicles as well as small corpus luteal cyst with surrounding inflammatory changes.

Case Discussion

Ultrasound and MRI features of pyosalpinx with secondary pelvic peritonitis.

It should be differentiated from a simple hydrosalpinx by the presence of:

  • thick-walled enhancing fallopian tube
  • surrounding inflammatory changes
  • restricted diffusion of fallopian content on DWI/ADC

The treatment is surgical.

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