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Can a Dr Feel a Uterus in Obesity Women

Written By Thursday, February 17, 2022 Add Comment Edit

LEARNING OBJECTIVES FOR Test half dozen

After completing this periodical-based CME action, participants will exist able to:

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Discuss the specific imaging challenges presented by obesity in women with a gynecologic condition.
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Identify specific solutions to the imaging challenges presented by obesity in women with a gynecologic condition.
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Describe the implications of obesity in benign and malignant gynecologic conditions.

Introduction

Obesity is a major global health business organization that affects all ages, socioeconomic groups, and countries. Although men take higher rates of overweight, women have higher rates of obesity. In the United States, more than 60% of women are overweight or obese, with more than than one-third considered frankly obese. Obesity is a major gamble gene for noncommunicable diseases such equally diabetes mellitus, cardiovascular illness, hypertension, stroke, and specific cancers. More specifically, obese women take higher rates of endometrial, chest, and colon cancer; decreased fertility; increased failure of oral contraceptives; and increased rates of pregnancy complications and cesarean delivery. Obese women also tend to receive fewer pelvic examinations and are less likely to participate in screening programs such every bit the Papanicolaou test. In the United States, national costs attributed to overweight and obesity were estimated at $147 billion per year in 2008 (i). It is well recognized that children of obese parents are more likely to go obese adults; thus, we conceptualize a progressive ascent in obesity rates (2). Coupled with the increased incidence of obesity is a strong push button to utilise imaging to assist solve health issues in a timely manner. Unfortunately, the obese patient may experience a lower quality of and less access to imaging (3). Obesity can contribute to missed diagnoses, nondiagnostic results of imaging studies, imaging examination cancellation because of weight or girth restrictions, scheduling of inappropriate examinations, and increased radiations dose exposure. Providers of medical imaging need to exist aware of the specific challenges presented by obesity in women with a gynecologic status.

The aim of this review is to place central areas in which obesity affects the imaging care of women with pelvic weather condition and to outline strategies to accost these areas. Showtime, a definition of obesity is provided, too as data on the diagnosis and management of fat disorders and their imaging challenges and solutions. Then an overview of the choice of an imaging modality is provided, and the modalities of radiography, fluoroscopy, interventional radiology, ultrasonography (US), computed tomography (CT), magnetic resonance (MR) imaging, and nuclear medicine imaging are covered. Finally, the implications of obesity in benign or acute pelvic conditions and in malignant pelvic conditions are presented.

What Is Obesity?

Obesity is the most visible symptom of a complex medical disorder. Fundamentally, there is an imbalance between caloric intake and energy expenditure, but the outcome will chronicle to the individual's genetic phenotype, hormonal balance, cultural heritage, and socioeconomic surround (2).

The nearly practical and commonly used definition of obesity is a body mass index (BMI) greater than 30 kg/m2 (4).

The overweight category encompasses a BMI of 25–29.9 kg/m2 (Tabular array ane) (four).

Table i Weight Classification on the Basis of BMI

Table 1

Diagnosis and Management of Fat Disorders

The key limitation of BMI is that information technology uses absolute weight rather than the distribution of fatty and lean musculus mass content.

Visceral fat is believed to be more closely associated with morbidity and bloodshed than subcutaneous fat is.

The classic android "apple shape" is associated with fundamental, or visceral, adiposity, whereas the gynecoid "pear shape" is associated with gluteofemoral adiposity (Fig 1). The android apple shape is more than associated with men, and visceral fatty is more closely related to the development of cardiovascular disease, the metabolic syndrome, and other chronic disease (v). This relationship may explain why the relative risk of death in people with a high BMI is greater for men than for women (5).

Noninvasive methods of quantifying body and organ fatty distribution take become an important component of obesity inquiry and management. Radiologic techniques such as dual x-ray absorptiometry, CT, and MR imaging provide direct cess of body fat and its distribution. MR imaging is condign established as the near reliable method that does not involve ionizing radiation and thus is applicable to all age groups, with the potential for longitudinal studies over time.

Imaging Challenges and Solutions

One in five Americans is estimated to be frankly obese, with a BMI greater than 30 kg/m2. The fastest growing segment of the overweight and obese population is the morbidly obese or bariatric patient, that is, anyone who has limitations in health care related to their weight, shape, or width. Typically, this includes whatsoever patient with a BMI greater than 40 kg/m2 or weighing more 350 lb (159 kg). The claiming for medical imagers is to notice ways to successfully epitome the obese patient.

Choice of the appropriate imaging modality is the first pace in the successful imaging of the obese patient. The clinical indication, the patient's weight, and the body diameters are three primal factors to consider before scheduling an test. For example, some patients who meet the tabular array weight limits for CT or MR imaging may accept a girth in excess of the gantry bore diameter. A useful rule of thumb is that if a patient tin fit onto a CT scanner or MR imaging unit (past weight and girth), image quality is generally acceptable. For imaging specialists, the distribution of adiposity and body diameters may accept more relevance than actual weight or BMI in selecting the most appropriate examination.

The challenges that are common to all imaging techniques are the limitations related to patient weight and girth. The imaging squad should be enlightened of standard table weight limitations and gantry diameters. Exceeding these limitations may decrease the life span of the table, forfeit warranties, or risk patient injury. Many of the modalities—in particular, radiography, fluoroscopy, nuclear medicine imaging, and CT—take common bug of quality compromise related to increased attenuation of the axle and a decreased signal-to-noise ratio (SNR).

One survey estimated a national availability of large-weight-chapters (>450 lb [>204 kg]) CT or MR imaging units in hospital emergency departments in the United States of 10% for CT and 8% for MR imaging. In academic medical centers, these numbers increased to 28% and 10%, respectively (iii). Manufacturing companies take been responsive to the changing population demographics with the development of "up-sized" equipment with larger fields of view, gantry diameters, and table weight-bearing load capacities (Table ii) (5,6). It is important to be aware that the constructive gantry aperture for CT or MR imaging is typically 15–eighteen cm less (vertical diameter) than advertised considering of the table thickness. MR imaging is the modality least affected by adiposity; withal, standard conventional units cannot accommodate patients who weigh more than 350 lb (159 kg) or have a girth of more than 60 cm. Using a wrap-and-constrict technique may achieve a temporary reduction in girth, with the added advantage of potentially minimizing artifacts associated with an disproportionate overhanging pannus.

Tabular array 2 Industry Standards for CT, MR Imaging, and Fluoroscopy

Table 2

Special considerations should be given to scheduling and transport of the bariatric patient. Requisitions that request weight information may flag a case for consultation earlier arrival to optimize fourth dimension slot scheduling and may alert the radiologist to cull the virtually appropriate examination. Specialized equipment required to transport the bariatric patient may not be readily available, leading to transport delays. The extrawide diameter of large-capacity weight-bearing stretchers or wheelchairs may present difficulty in traversing narrow corridors or doorways. An innovation that has reduced time lost in the MR imaging unit of measurement has been the evolution of mobile-uniform tabular array slides that let the patient to be transferred and positioned outside the MR imaging room.

The large abdominal pannus, potentially weighing more than than 100 lb (45 kg), deserves special consideration. A semirecumbent, oblique, or decubitus position may be helpful to avoid aortocaval compression, which can lead to hypoxemia and hypotension. This is especially important in interventional procedures in which the issues of respiratory compromise can be compounded by the addition of conscious sedation. Close monitoring of the patient's level of consciousness and vital signs is of import. Other special considerations include the availability of specialized equipment such equally longer needles or catheters and larger sphygmomanometer cuffs. Examinations that crave intravenous injections may be challenging in patients whose deep subcutaneous layer can act every bit a visual and palpation barrier to intravenous access. Usa guidance of peripheral intravenous access has been shown to be less time consuming and have fewer complications, compared with "blind" techniques.

Operational manuals that are formulated to plan the transmission handling risks should be widely available to imaging staff. Generally, the bariatric patient, particularly when mobility is hindered, may betrayal the imaging team to risks of musculoskeletal-related disorders. Lifting cranes are helpful to transfer bariatric patients with express mobility. At times, a crane may be used to leverage office of the patient'south weight and thus decrease the weight resting on an test table. This technique is generally more helpful in the examination of peripheral and cranial structures than examination of the pelvis (Table 3) (7).

Table 3 Solutions to Clinical, Scheduling, and Ergonomic Issues

Table 3

Familiarity with the optimization of imaging techniques across all modalities is crucial to convert potentially suboptimal examinations into diagnostic-quality studies. It is important to develop in-business firm large-patient protocols for each modality. Data on weight and discontinuity limits should be readily available in each department, both at the point of scheduling and at the point of test performance.

The imaging specialist must judge whether the limitations imposed past backlog adiposity warrant a change in protocol, additional imaging, or adaptation of current techniques. Furthermore, the lack of widespread national availability of up-sized or bariatric equipment may necessitate examination cancellation or transfer of the patient.

Choice of Imaging Modality: Overview

Despite the best efforts, images remain more than difficult to acquire and interpret in the obese woman. Furthermore, at that place remains a paucity of evidence on which to base determinations of best practices for gynecologic imaging of the obese woman. The results of clinical evaluation of any woman with a pelvic disorder—in particular, acute pelvic hurting—are often nonspecific, and imaging is relied on heavily to achieve an accurate diagnosis. The clinical test is fifty-fifty more limited in the obese woman, resulting in an even greater reliance on imaging. The states is typically the first-line imaging modality of selection in a woman of reproductive age (including pregnant women) who is suspected of having any gynecologic condition. Although US is considered the modality virtually impeded by abdominal adiposity, a combination of up-to-date technology and the transvaginal route tin can provide diagnostic imaging of the pelvic organs in many situations (8). MR imaging is preferred over CT for meaning patients or women of reproductive historic period in whom a gynecologic condition is suspected merely for whom US has not provided a diagnostic answer (2,9). CT is generally preferred for gastrointestinal or urologic disorders; however, the first-line investigation will depend on both the clinical indication and the patient's body habitus. Despite its diagnostic utility, pelvic CT should be used selectively in women of reproductive age and children because obese patients may receive a essentially higher radiation dose than nonobese patients.

Radiography

Radiography is express past a poor SNR and diminished contrast that is due to increased attenuation and scatter. When faced with a bariatric patient, some potential solutions include increasing the peak kilovoltage (kVp setting) and the tube current–time product (mAs setting), the employ of multiple cassettes to ensure coverage of the expanse of concern, the use of a grid to reduce scatter, and an increased speed of film development. Digital viewing provides the ability to conform window and level settings. Automated exposure control will deed to increase exposure factors, to achieve a level for optimum quality in the obese patient, although longer exposure times may result in move artifacts (Table iv).

Table four Radiography-related Solutions to Imaging Issues

Table 4

Fluoroscopy

Fluoroscopy is primarily limited past the aperture diameter and tabular array weight limitations. Fluoroscopic procedures may be prolonged, with increased dosage per frame, which results in relatively high radiations doses. High doses tin be minimized past the use of pulsed fluoroscopy. In patients who exceed the aperture or table weight limitations, the use of serial radiographs may partially substitute for the lack of real-fourth dimension imaging. Image quality considerations are similar to those of radiography (Tabular array 4).

Interventional Radiology

Nosotros recommend that all patients with a BMI greater than xxx–35 kg/mtwo should undergo a preprocedural consultation with the interventional radiologist. A review of prior imaging may help in selecting (a) the most appropriate imaging technique for the indication and (b) which position might provide the most direct pathway (Fig two). Additional considerations would include (a) recognition of the increased risk of respiratory low with conscious sedation, (b) challenging intravenous access, (c) choosing instruments of adequate length, and (d) the difficulties with optimizing and maintaining positioning. Blood pressure level monitoring may crave special large claret pressure cuffs. For pelvic drainage procedures, a transrectal or transvaginal approach has the advantage of bypassing the abdominal pannus. For the obese patient undergoing a fluoroscopically guided procedure, there is a chance of high skin dose that is due to loftier absorption of low-dose photons at pare level, particularly in a prolonged process. Strategies to minimize dose include tube rotation (to distribute the dose), keeping the tube at a safe distance, and using pulsed fluoroscopy to reduce dose. Substitution of CT guidance for fluoroscopic guidance may decrease dose exposure and better visualization (Table 4).

Figure 2

Figure ii Axial CT image obtained afterward radical vulvectomy for cancer in a 62-year-old adult female. CT-guided biopsy of the distal right external iliac lymph node (arrow) was performed because adiposity precluded United states guidance of the biopsy.

Ultrasonography

US is considered the radiologic modality most afflicted by obesity because of the actual depth of insonation required and the attenuation of the ultrasound axle (viii). Notwithstanding, in the female gynecologic patient, US remains a start-line tool of investigation in the majority of scenarios considering of the piece of cake accessibility and the lack of ionizing radiation or absolute weight/girth restrictions, plus the availability of transvaginal imaging. Transvaginal United states of america provides an opportunity to bypass the abdominal pannus and evaluate the pelvic organs with a loftier-frequency transducer providing high-resolution images of structures within its range. The use of the hand on the lower belly to bring structures closer to the probe may assistance in some situations. There is a paucity of show-based literature describing the implications of obesity on transvaginal U.s.a.; however, in exercise, it is often considered a "rescue" for an inadequate transabdominal US study for assessment of the uterus and ovaries (Fig 3).

Information technology is important to exist aware of the special ergonomic challenges involved in gynecologic imaging of the obese patient. Even when good ergonomic practices are applied, the key risk factors associated with work-related musculoskeletal disorders, such as repetitive motion, forceful or awkward position, and prolonged duration of pressure, may still exist. Strategies that may exist helpful include stretchers that will readily elevate and descend to appropriate heights for imaging or patient transfer, vocalisation-activated commands, and foot pedals that permit the sonographer to piece of work from either side of the table. Task rotation is important; thus, being aware of the scheduling of bariatric patients to permit interim "balance" for the sonographer is important. In our practise, we have found that the transvaginal arroyo is a ways of obtaining high-quality images of the uterus and ovaries (or the fetus during early anatomic evaluations) while minimizing ergonomic stress for the sonographer.

The abdominal pannus acts to limit visualization, both by the actual depth of insonation required and the attenuation of the ultrasound beam, with increased backscatter resulting in a decreased SNR. Utilizing the everyman-frequency transducer available (lower frequency allows for greater penetration) and choosing a pathway with relatively less intervening adipose tissue are of import. The intestinal pannus is generally thickest between the pubic symphysis and the umbilicus; thus, scanning above the umbilicus or below the pannus may be helpful. Scanning through the abdominal pannus is an ergonomic challenge requiring the sonographer to exert sustained force per unit area to optimize images. The patient can exist enlisted to assistance lift the pannus while the sonographer scans beneath it. Turning the patient into a lateral decubitus position volition cause the pannus to fall away, providing a window through the lateral flank when the transducer is oriented medially. An abdominal retraction system (KanguruWeb; Milamy Partners, Yarmouth, Me) was designed to hold back the abdominal pannus during groin access procedures, such as femoral puncture (7). We have successfully used this organization in significant patients and in pelvic examinations to scan beneath the pannus as it is beingness retracted, thus decreasing the sonographer's fatigue and ergonomic stress. We accept also found that cutting a hole in the centre portion of the web can provide an additional access window, which has been particularly useful for imaging the fetus via the maternal umbilicus, which is the thinnest part of the abdominal wall (Fig 4) (vii).

Bones maneuvers such every bit repositioning the transducer to better the scanning angle, avoiding reverberation antiquity, and narrowing the sector width may contribute to an improved paradigm. Advanced technology such as harmonic imaging to improve edge resolution, compound imaging to reduce angle-generated and speckle dissonance artifacts, and postprocessing tools to improve the SNR and margin definition may convert a suboptimal examination into an acceptable examination. Harmonic imaging is particularly useful in that the maximum intensity of the harmonic waves generated is directly proportional to the nonlinearity coefficient of the tissue. Considering fatty has the highest nonlinearity coefficient, it volition act to increase the harmonic waves created, resulting in an effective increase in beam frequency and an improved image (10). When it is available, a preset way for the obese patient, ofttimes called the "penetration" mode, should be chosen to better image this population. Newly adult i-MHz transducers, coupled with the adoption of (a) beam-forming algorithms to better model obese patients and (b) tissue aberration correction programs to adjust for the speed of sound in adipose tissue, volition provide increased depth, increased penetration, and improved image quality (Fig five). The evolution of crystal array transducers and isotropic transducers that allow real-time multiplanar imaging may prove helpful in the obese woman (2).

In the performance of sonohysterography, the main concerns are achieving acceptable delineation of the neck. An extralong (fifteen-cm) Graves speculum can be substituted for the large (12-cm) Graves speculum. A redundant vaginal wall may be held dorsum by covering the speculum with a sterile glove or condom, the tip of which is cutting to let opening of the speculum (Table 5).

Tabular array 5 U.s.a.-related Solutions to Imaging Bug

Table 5

Although this review is not focused on obstetric issues, the literature is clear that the overweight or obese pregnant patient is at a disadvantage for routine US fetal imaging (ii,xi). Early reports indicate that in that location may be a role for early anatomic transvaginal evaluations (thirteen–15 weeks) in this subset of pregnant women who are at increased risk for fetal congenital anomalies.

Computed Tomography

CT imaging of the pelvis is more often than not acceptable in patients with balmy or moderate obesity; however, the morbidly obese patients in obesity grade III can nowadays a challenge. The main limiting factors for CT imaging in obesity are weight, girth/size, and radiations exposure. The size limitations further include problems with true discontinuity, field of view (FOV), positioning, and out-of-field and photon starvation artifacts (12). A moderate amount of intraabdominal fat tin ameliorate depiction of organs past providing natural dissimilarity between structures. In general, if the patient can fit into the gantry, the images volition be diagnostic.

Weight and Girth.—Scanning patients who exceed the manufacturer's set weight limit for a tabular array can potentially impairment the table and void insurance or service warranties. Although the tables are oft tested to two to 4 times the stated limit, the manufacturer'south warranties volition embrace costs but to the stated limit (3). Thus, it is all-time to obtain the measured weight of the patient just earlier the browse, rather than using estimates or inaccurate historical information. Newer models of dedicated bariatric scanners have weight limits as big as 50% more those of nearly currently used equipment; that is, newer models will accommodate patients weighing from 450 to 650 lb (204–295 kg). Likewise, the utilise of other commonsense approaches, such as elevating the patient to the expected table position and then transferring the patient, rather than using the table to elevate the patient, using the manual or slow controls, and decreasing the cantilever forces, may reduce strain on the mechanical components. Thus, for scanning the pelvis, it may be all-time to position the patient feet first. Typically, the industry-standard discontinuity bore in multidetector CT scanners has been 70 cm; still, in accounting for the table thickness, the true vertical-aeroplane aperture is reduced by 15–18 cm. Again, the industry standards are improving, with increasing numbers of bariatric scanners that have apertures in the eighty–90-cm range. A significant reduction of the patient's girth can temporarily be accomplished past appropriate wrap-and-constrict methods with either makeshift measures or commercially bachelor binders. An added advantage of bounden the pannus is a decreased likelihood of it hanging asymmetrically to the side, which can lead to beam-hardening and photon starvation artifacts.

Artifacts.—It is important to position the patient such that the region of interest is centered within the FOV, permitting a decrease in the out-of-field artifacts. Although the scanned FOV is larger, the reconstructed FOV is the true representation of the view obtained. This is fifty cm for most scanners. Two bones postprocessing techniques are bachelor for capturing the data available between the reconstructed and scanned FOVs. Although not bachelor on all scanners, these techniques allow either a global increment in FOV or the ability to focus the FOV to the region of involvement (13). The out-of-field artifact occurs as the image reconstruction algorithms presume that all attenuation is coming from within the scanned FOV and reproduce this as an expanse of increased attenuation on the image. This artifact can be reduced by the use of scanners with a larger FOV, the wrap-and-tuck method, and the awarding of artifact removal software. The photon starvation artifact increases the noise, thereby significantly reducing image quality. This can be ameliorated by various techniques, such every bit using scanners with higher-chapters generators, maximizing the mA setting, including waiting for the tube to cool earlier imaging the bariatric patient, decreasing the pitch, increasing the rotation fourth dimension, increasing the reconstruction section thickness, using "soft" reconstruction algorithms such as adaptive statistical iterative reconstruction (ASIR), or using dual-source CT (fourteen). Significant improvement of image quality can be achieved past using a combination of the previously suggested techniques.

Radiation Exposure.—Clearly, some of the image optimization methods detailed previously volition increment radiation exposure to the patient. In contempo publications, investigators have suggested that a twoscore% increment in weight may increase the mean organ dose by 100% (15). The dose-length product is automatically displayed on newer CT scanners to provide a representation of the integrated dose beyond the scan length. This value can then be used to estimate constructive dose with conversion factors. From a applied perspective, a nonobese women undergoing a pelvic CT exam might conceptualize a dose-length product of 120–150 mGy·cm, whereas for a woman with a BMI of fifty kg/one thousand2, the dose-length production would approximate 450–500 mGy·cm. All the same, multiple strategies can be applied to reduce the radiations dose exposure to the bariatric patient. These strategies include (a) scanning without automatic exposure controls, (b) accepting more noise in the bariatric patient, in part because of lowered expectations and in part considering of more fat outlining the organs and increasing the intrinsic contrast, (c) increasing the department thickness, (d) using orthogonal reformatted images (16,17), and (eastward) using soft algorithms such as ASIR, a dissonance reduction algorithm that can allow as much equally a 40% dose reduction for similar image quality (eighteen) (Figs 6, 7).

Conversion of a poor-quality CT study to a diagnostic CT study. (a) Axial CT image obtained with a suboptimal technique (400 msec/696 mA; section thickness, two.five mm; 120 kVp) is almost nondiagnostic because of the out-of-field artifact (arrowheads), the photon starvation antiquity (lengthened increased racket), and poor centering. (b) Improved-quality axial CT epitome (echo browse inside 12 hours) obtained with an improved technique (k msec/753 mA; section thickness, five mm; 120 kVp) and with the patient wrapped and tucked and better centered. Image conspicuously shows a right iliopsoas abscess (pointer).

(a) Centric CT image has poor quality acquired by the out-of-field artifact (arrowheads) and the photon starvation antiquity (diffuse increased racket). (b) Improved-quality axial CT image (repeat scan within 12 hours) was obtained with an improved technique and with the utilise of ASIR, which is a noise reduction algorithm that enables a decreased radiation dose exposure while maintaining image quality.

Intravenous Dissimilarity Material Dose Considerations.—The most important patient-related gene affecting vascular and parenchymal enhancement with administration of intravenous iodine-based contrast fabric is trunk weight. Typically, the iodine dose is adjusted for body size on a one:ane basis in linear manner proportional to torso weight. For a given weight, an obese patient will have a relatively smaller blood volume than a large patient. This difference may result in an overestimation of the dose of contrast material required in obese patients because body fat is relatively hypovascular, compared with body organs. Adjustment of the dose requirement on the basis of lean body weight may be more appropriate than adjustment on the footing of weight (Table 6). If a patient is markedly obese, an additional consideration is the degree of x-ray beam handful and attenuation caused by the large volume of subcutaneous and visceral fatty; thus, the iodine dose may need to be adjusted upward to permit lesion conspicuity (xviii). The timing of contrast enhancement is unaffected by weight.

Table 6 CT-related Solutions to Imaging Bug

Table 6

MR Imaging

MR imaging is considered the modality least affected by obesity because the radiofrequency used in MR imaging can penetrate large amounts of fatty, compared with ionizing radiation or audio waves.

Physical Restrictions.—The typical weight limit for a conventional cylindrical MR imaging table is just 350 lb (159 kg) with a cylindrical MR imaging unit of measurement diameter diameter of sixty cm, less than that for CT (Tabular array 2) (5,6). The typical bore length of a conventional cylindrical MR imaging unit is 170 cm (v.five ft), which combined with a tight fit in the bore, can compound a patient's sensation of claustrophobia (6), which may, in plow, consequence in termination of the test at the request of the patient. In a tight fit, information technology is prudent to place a cotton fabric betwixt the patient'due south skin surface and the gantry to minimize the risk of skin burns. A clammy skin surface, acting as a conductor, may further increment the risk of skin burns.

Quality Issues.—The quality of MR images depends on the SNR acquired from the patient. Receiver coils, which are used for almost every MR imaging examination, are designed to fit snugly against the body part being evaluated, to optimize the SNR. A general dominion for surface coils is that the sensitivity of the coil decreases essentially across a distance equal to the coil bore. In obese patients, however, the radiofrequency coils must have a larger diameter to fit across the patient'south greater girth, which inherently decreases the SNR (6). Improved coil applied science with an increased number of channels and an increased number of coil elements can preserve the SNR in an obese patient without increasing acquisition times. The SNR is linearly proportional to voxel volume. Voxel volume depends on the FOV, section thickness, and matrix size, all of which are affected by the patient size. The larger FOV needed to epitome an obese patient decreases the in-plane resolution of the images. Indicate strength and acquisition times can be increased to enhance paradigm quality; nonetheless, increasing the indicate strength is limited by the radiofrequency power deposition. Increasing the scan times for a patient who is already uncomfortable and claustrophobic can lead to motion artifacts or incomplete examinations. The typical maximum FOV for a i.5-T cylindrical-bore MR imaging unit is approximately 40–50 cm, compared with 35–twoscore cm for a vertical-field "open" MR system. The smallest FOV is used to image the area of involvement without inducing a wraparound artifact (Table 7). A "no stage wrap" option can be used to minimize this artifact (19) (Fig 8).

Figure 8

Figure eight Centric contrast-enhanced MR paradigm obtained in the portal venous phase later on gadoxetate disodium (Eovist; Bayer, Toronto, Ontario, Canada) injection in a man who weighed 350 lb (159 kg). The image has adequate diagnostic resolution. Note the parallel image artifact (arrow), the exclusion of the lateral flanks from evaluation, and the heterogeneous fat suppression.

Table vii MR Imaging–related Solutions to Imaging Problems

Table 7

Newer Innovations.—The open vertical-field MR imaging unit (0.iii–i.0 T) with a forty-cm gap can accommodate a patient weight of every bit much as 550 lb (249 kg) (xix), at a cost of lower diagnostic image quality. Newer designs have improved physical chapters by tolerating weights of as much every bit 550 lb (249 kg), aperture diameters of 70 cm, and shorter bores (125 cm) while operating at 1.five T. An interesting innovation is the mobile MR imaging–compatible table slide, which can be used to prepare the patient outside the room, thus reducing the arrangement's idle time. MR imaging–compatible cranes may aid in mobilizing patients.

Nuclear Medicine Imaging

Imaging the pelvis of the bariatric patient may include the need for nuclear medicine imaging, particularly in gynecologic oncology. The chief limiting factors are related to dosage calculation and injection, table limitations and camera setup, and prototype quality and diagnostic considerations. Image quality considerations include incomplete whole-torso coverage and limitation of quantification, specially for positron emission tomography (PET) (20).

Patient Grooming and Dosage Considerations.—The standard dose of radiopharmaceuticals in adults is based on an ideal standard weight of 70 kg. Obtaining acceptable epitome quality in an obese patient may require the use of a higher dose; even so, the radiation dosage recommended past the International Committee on Radiological Protection limits the corporeality of dose increase permitted. The resultant image may be suboptimal considering of a combination of reduced SNR and increased scatter. Fluorine eighteen fluorodeoxyglucose (FDG) has a full dose restriction of 925 MBq (25 mCi) (21). In the literature, investigators suggest that image quality tin can be improved by longer scan times, whereas dose adjustment does non announced to have a meaning effect in patients who are overweight or mildly obese (22,23).

FDG, the most common tracer used for routine PET studies, is a glucose analog. The tracer accumulates preferentially in malignant cells; thus, information technology can be used to monitor response or disease progression.

Obtaining a claret glucose value before the imaging examination is good practice to ensure that claret saccharide values are appropriate, an important event in obese patients, who commonly accept coexistent diabetes mellitus. Hydration is peculiarly important in pelvic PET imaging studies considering a high concentration of FDG in the urine may obscure smaller or weakly gorging PET lesions.

Tabular array Limitations and Photographic camera Setup.—Most PET tables have a weight limit of 400 lb (181 kg). Every bit described in the CT section, exceeding these limitations may decrease the life span of the tabular array, forfeit manufacturer warranties, or be unsafe. Multihead gamma cameras can be helpful to allow coverage of the larger expanse of an obese patient by permitting manual photographic camera placement. For a gamma photographic camera integrated with a CT scanner, gantry diameter is typically 80 cm, which may limit the accommodation of obese patients. For some studies (eg, ventilation-perfusion scan), a mobile gamma camera can be placed above the patient'south bed or adapted to the patient'due south sitting position. Unfortunately, most protocols require the patient to be in a supine position.

Prototype Quality and Diagnostic Considerations.—Poor SNR limitations can be partially addressed by lengthening or delaying acquisitions times and past the utilization of multidetector systems to attain college statistical counts. Watson et al (24) estimated that for an equivalent SNR ratio, a 120-kg person would need to be scanned 2.iii times longer than a 60-kg person for a PET test. With longer acquisition times, there is an increased risk of patient movement; thus, close attention to a secured comfortable position is of import. Sandbags can help minimize patient motion. In some procedures, such as bone scans, delaying acquisitions to occur every bit long as 4 or 5 hours afterward injection may aid to clear soft-tissue activity, resulting in an improved target-to-nontarget ratio.

Artifacts and Quantification Challenges.—When the patient's girth exceeds the FOV, cropping and beam-hardening artifacts may occur. Wrap-and-tuck methods can provide a temporary reduction in girth. The skin fold of the abdominal pannus may crusade an apparent increased uptake in a linear artifact style. Standardized uptake values should be used with circumspection in the obese population because they may result in an overestimation of values. Utilizing the body surface area or lean torso mass may issue in less variability.

PET Integrated with CT.—PET integrated with CT (PET/CT) is an of import imaging modality in patient management, especially in oncology. PET/CT provides a unique combination of functional and anatomic data in a single imaging procedure. Integrated PET/CT is more accurate for epitome localization and characterization than either modality alone; however, the FOV for PET/CT may exist smaller than that of PET alone. Imaging the obese patient is more probable to issue in CT truncation (occurs when the girth exceeds the FOV) or streak artifacts (rim high activity at the truncation margins). For PET/CT, truncation artifacts as well occur because of the divergence in the FOV betwixt the CT study and the PET study. Even when truncation correction algorithms are applied during epitome reconstruction, it may be difficult to ensure proper quantification. Ensuring that the expanse of interest is key within the FOV is important to minimize the upshot of these artifacts (Table viii).

Table 8 Nuclear Medicine Imaging–related Solutions to Imaging Issues

Table 8

Implications of Obesity in Benign or Acute Pelvic Weather

US is the imaging modality of pick in benign or acute gynecologic conditions in the obese woman, similar to the nonobese woman. In the young female patient, if the findings from the US examination are inconclusive or nondiagnostic, MR imaging is the preferred 2d-line modality for imaging. Contrast material is not used if the patient is meaning. If the serum examination for the beta subunit of human being chorionic gonadotropin (β-hCG) is negative and the patient is suspected of having a nongynecologic status, the 2d-line modality for imaging would be either MR imaging or CT. Situations in which boosted imaging may be helpful include (a) CT or MR imaging to evaluate the extent of collections in complicated pelvic inflammatory disease and (b) CT to guide pelvic collection drainage. The postpartum catamenia is a time when the obese woman is at increased chance for pelvic infection, compared with the nonobese woman (25). Retained products of conception, a potential nidus for infectious morbidity, is well evaluated with transvaginal U.s.a.. In complicated endomyometritis, MR imaging may provide additional information on the extent of involvement (Fig 9).

Acute Appendicitis

In general, CT is the imaging modality of selection for gastrointestinal conditions. The main exception is for the diagnosis of acute appendicitis, in which protocols depend in part on local availability and expertise.

Although obesity remains an contained predictor of a nondiagnostic US test, we continue to utilise U.s.a. every bit an initial screening examination, especially considering it can exist used to diagnose other conditions, such as those originating from the ovary. The clinical manifestation and the incidence of appendicitis are similar in obese and normal-weight women; all the same, the findings at physical test are less reliable in obese women, leading to a higher rate of appendectomy without appendiceal disease (then-called negative appendectomy) (26). Overall, women account for the vast bulk, approximately lxx%, of those without appendiceal disease at appendectomy (27). Preoperative CT has been demonstrated to lower the negative appendectomy rate in the obese population, with the about dramatic benefit in the morbidly obese grouping. In a immature or pregnant female patient, MR imaging is a reasonable second-line modality for imaging. Although we favor U.s. as a first-line imaging tool, nosotros recognize that many centers offering MR imaging as an initial screening modality for astute appendicitis in obese significant women. This is particularly valuable as gestation progresses and the appendix becomes progressively more difficult to describe with Us. It is of import not to delay the diagnosis of acute appendicitis in pregnancy, to avoid the risk of perforation, which in turn is associated with premature labor and increased fetal morbidity and mortality (28).

Acute Diverticulitis

The incidence of astute diverticulitis is rising in the young obese population (younger than forty years), with a recent commodity estimating the incidence to be as high as 21.2%, with a predilection for immature men (63.6%) (29). The risk for perforation or abscess is doubled in obese women, compared with normal-weight women (29). Although we do not recommend US as a first-line screening tool, it is useful to be familiar with the sonographic findings of diverticulitis. U.s.a. also tin can be used in this setting to ensure that a gynecologic trouble is not the cause of the clinical symptoms (Fig 10). CT is generally considered the first-line imaging modality of choice, although US can play a part in expert easily.

Acute complicated diverticulitis in a morbidly obese 49-year-old woman presenting with nonspecific pain in the left lower quadrant. (a) Transvaginal US image shows a gas-containing hypoechoic drove (white arrow) surrounded by hyperechoic fat, as well as a thickened sigmoid colon wall (black arrow). (b) Sagittal CT prototype shows the gas-containing abscess (white arrow) arising from the inferior aspect of the sigmoid colon (black arrow).

Abdominal Surgery

Intestinal surgery in obese women is lengthier and is associated with greater blood loss and wound infections. It is speculated that the adventure of wound infection is related to factors such equally relative insulin resistance, hyperglycemia, and the large wound surface area with decreased oxygen tension and subtherapeutic concentrations of prophylactic antibiotics.

Necrotizing Fasciitis

Necrotizing fasciitis is an extremely rare, chop-chop progressive, and often fatal infection of the lower portion of the abdomen or pelvis (Fig 11). Obesity, independent of diabetes, remains a significant take chances gene for this status (xxx). The acute clinical presentation of a adult female, especially in the postpartum or postsurgical period, with sepsis and inordinate pelvic pain should enhance the suspicion of necrotizing fasciitis. Fournier's gangrene is a form of necrotizing fasciitis that primarily affects the perineal, genital, or perianal regions and has similar predisposing factors of obesity and diabetes mellitus. The decease rate from necrotizing fasciitis in women is as high as 50%, compared with 7.7% in men. This deviation may exist related to a predisposition in women for infection to extend into the retroperitoneal and peritoneal spaces (31). CT cess of the pelvis should be considered in a women afflicted by this potentially lethal disease.

Figure 11

Figure eleven Postmortem diagnosis of extensive necrotizing fasciitis of the retroperitoneum secondary to group A Streptococcus infection in a 61-twelvemonth-old woman who presented in extremis and died soon after admission. Antemortem axial CT image shows bilateral leakage of contrast material from the necrotic ureters (arrows).

Chronic Anovulation

The obese adult female is at greater risk for chronic anovulation. The most common etiology is polycystic ovarian syndrome, which can result in infertility and dysfunctional uterine bleeding.

Pelvic Floor Dysfunction

Pelvic floor dysfunction affects approximately 60% of morbidly obese women, with the severity of urinary incontinence influenced by both the duration and the degree of obesity (32,33). Assessment of the pelvic floor can be accomplished with either Usa or MR imaging. In our experience, translabial US imaging of the pelvic floor is not significantly impeded by obesity and overcomes the inability of MR imaging to identify mesh implants.

High-Risk Obstetric Status

Obese women are considered high-chance obstetric patients on the basis of multiple comorbidities, the increased rates of obstetric complications, and the increased incidence of built fetal anomalies and growth disturbances. US is generally the imaging modality of selection in nonacute gynecologic or pregnancy-related conditions. In our experience, MR imaging plays a similar role in the evaluation of nonacute gynecologic or pregnancy-related conditions as in the nonobese patient. The obese gravida may exist more limited past body girth restrictions than the nonobese gravida.

Implications of Obesity in Malignant Pelvic Atmospheric condition

Obesity is associated with increased mortality for all cancers, with the highest relative take chances attributed to uterine cancer in morbidly obese women (Table ix) (34). The proportion of all deaths from cancer attributable to weight is estimated to exist as high as twenty% in women.

The heaviest women (BMI ≥ 40 kg/one thousand2) have death rates 62% higher than women of normal weight.

Tabular array 9 Influence of Excess Body Weight on the Relative Risk of Decease from Cancer in Women

Table 9

There is a clear consistent association between obesity and decreased utilization of the Papanicolaou test for cervical cancer screening, which is likely related to multiple factors, including socioeconomic status and psychologic factors (35). Women with class III obesity are 40% less likely to undergo cervical cancer screening (36) (Fig 12). Colorectal cancer screening is the only cancer screening that is recommended for both men and women, thus providing the ability to direct compare the effects of gender and obesity. In women, the bulk of the literature suggests a negative clan between obesity and colorectal cancer screening, whereas in men the relationship is inconsistent (37).

Figure 12

Figure 12 Uterine carcinosarcoma in a 65-year-old woman with no gynecologic care or Papanicolaou test in more than than 10 years who presented with a 3-calendar month history of postmenopausal bleeding. Sagittal U.s.a. paradigm shows a thickened (21-mm) vascular endometrium (arrows) with poorly divers margins at the posterior aspect. The findings at histopathologic examination confirmed the diagnosis of invasive endometrial carcinosarcoma of the uterus.

Endometrial Cancer

The strongest take a chance factors for developing endometrial cancer are obesity and nulliparity (38). Obesity is associated with excess estrogen, with agile conversion to estrogen occurring in body fat depots. Excess or unopposed estrogens are associated with singular endometrial hyperplasia, a precursor for endometrial malignancy. At that place is strong evidence that ovarian androgen backlog syndromes, such as polycystic ovary syndrome, as well increase the adventure of endometrial cancer (39,40). Conflicting information be with regard to the benefit of transvaginal United states of america to detect endometrial cancer in women with postmenopausal bleeding and whether they would benefit from endometrial sampling (41,42). The incidence of endometrial malignancy is higher in obese women with postmenopausal bleeding (18%) or diabetes (21%), compared with nonobese women without these take a chance factors (8.0%). Given the high pretest probability for malignancy in obese diabetic women with postmenopausal bleeding, endometrial sampling is appropriate (43). MR imaging is the imaging modality of choice to ascertain the primary tumor and the extent of local pelvic disease. CT and MR imaging are both good options for assessing nodal involvement. PET/CT is advisable for assessing nodal involvement in loftier-form FDG-avid tumors. To our knowledge, there are no studies evaluating the best imaging modality in the obese adult female with endometrial cancer; thus, nosotros recommend post-obit similar protocols to those used in nonobese women when possible.

Cervical Cancer

There is an increased incidence of cervical cancer among obese women, presumably because of the presence of added estrogenic hormones (36). The Papanicolaou test has been the factor nigh responsible for a decrease in cervical cancer mortality on the basis of early diagnosis, merely the obese adult female is less likely to volunteer for cervical cancer screening programs and thus has a higher take a chance for invasive cervical cancer at the time of diagnosis. Imaging is important for triage into a surgical or a chemoradiation treatment plan. MR imaging is the imaging modality of choice to accurately stage local tumor brunt and invasion. FDG PET is considered as skillful as or potentially better than other modalities for assessing nodal, extrapelvic, and bone metastases. FDG PET is also helpful in predicting patient outcomes when the maximum standardized uptake value is incorporated into the assessment (44). To our cognition, there are no studies evaluating the best imaging modality in the obese woman with cervical cancer; thus, we recommend following similar protocols to those used in nonobese women when possible.

Ovarian Cancer

The relationship betwixt obesity and ovarian cancer is unclear. Women with ovarian cancer tend to present late with widespread disease, and no imaging method is recommended for screening boilerplate-risk women (45). In loftier-hazard women (positive findings for family history, genetic contour, or serum markers), the part of screening transvaginal Usa remains unclear in terms of upshot benefits. US is the imaging modality of option to characterize an ovarian lesion. MR imaging is excellent for characterizing adnexal masses that are indeterminate at US test (46,47). Cytoreductive surgery is the standard handling for ovarian cancer, and CT is the imaging modality of choice to ascertain tumor brunt and extent. PET or PET/CT is used with increasing frequency to diagnose and phase advanced disease and recurrence (48). To our knowledge, there are no studies evaluating the best imaging modality in the obese woman with ovarian cancer; thus, nosotros recommend following similar protocols to those used in nonobese women when possible.

Pelvic Surgery and Obesity

Pelvic surgery is complicated by obesity in terms of technical challenges and peri- and postoperative complications. Minimally invasive surgery, such as laparoscopy, does not announced to be significantly influenced by increasing BMI and is considered safer than conventional abdominal surgery (49). Contempo reports demonstrate the early success of robotic-assisted minimally invasive surgery in morbidly obese women, with this type of surgery permitting navigation around anatomic barriers, minimizing surgical fatigue, and decreasing the length of the hospital stay (50,51).

Conclusions

Diagnostic imaging plays a central role in the diagnosis and management of obese patients with a pelvic status. Recognition of the available equipment'southward limitations, imaging artifacts, optimization techniques, and appropriateness of modality choices is critical to providing good patient care to this health-challenged group.

For this periodical-based CME activity, the authors, editor, and reviewers have no relevant relationships to disembalm.

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Received: Mar 1 2012
Revision requested: Apr 9 2012
Revision received: June 26 2012
Accepted: July 17 2012
Published online: October four 2012
Published in print: Oct 2012

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Source: https://pubs.rsna.org/doi/10.1148/rg.326125510

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