Presentation
Pelvic pain.
Patient Data
significant thickening of the endo-myometrial junctional zone, predominantly in posterior uterine wall in keeping with adenomyosis
both ovaries are enlarged and located nearby, touching each other in the midline giving the "kissing ovaries sign" containing bilateral cystic lesions with hemorrhagic content and fluid-fluid levels describing a stratified pattern (shading sign) in keeping with bilateral endometriomas
thickened torus uterinus with multiple hemorrhagic foci in bilateral adnexal regions, along the posterior surface of the uterus and anterior perirectal regions
T2 hypointense thickening of the proximal medial portion of the uterosacral ligaments bilaterally
uterus, both ovaries and rectum are brought closer by constrictive adhesions /fibrotic bands leading to the recently described "cloverleaf sign" of deep infiltrating endometriosis.
no stricture or proximal bowel obstruction. No apparent round ligament, or anterior abdominal wall involvement
The images illustrate the cloverleaf sign when uterus, both ovaries and rectum are brought closer by constrictive adhesions which indicates deep infiltrating endometriosis.
Case Discussion
The MRI findings are most consistent with deep infiltrating endometriosis bilateral ovarian endometriomas and uterine adenomyosis.
The cloverleaf sign in deep infiltrating endometriosis is highly suggestive of a more complex surgery with longer operation time, a greater risk of bowel resection, and blood loss.
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