What is the initial treatment and follow-up approach for a patient with a history of Crohn's disease and suspected pelvic congestion syndrome due to enlarged tortuous ovarian veins on CT scan?

Management of Suspected Pelvic Congestion Syndrome in a Patient with Crohn's Disease

Initial Diagnostic Confirmation

The finding of enlarged tortuous ovarian veins on CT scan requires confirmation with ultrasound with Doppler as the initial imaging study of choice for diagnosing pelvic congestion syndrome. 1

• Ultrasound with Doppler should demonstrate specific diagnostic criteria: engorged periuterine and periovarian veins ≥8 mm in diameter, low-velocity flow (<3 cm/s), altered flow with Valsalva maneuver, and retrograde (caudal) flow in the ovarian veins 1

• If ultrasound findings are equivocal or nondiagnostic, proceed to MRI/MR angiography, which has diagnostic performance comparable to conventional venography and can directly demonstrate ovarian vein reflux 1

• The CT scan already performed may have demonstrated engorged periuterine and periovarian veins and can identify venous anatomic variants, but dedicated pelvic venous imaging is needed for treatment planning 1

Critical Consideration: Rule Out Mechanical Obstruction

Before attributing symptoms solely to ovarian vein incompetence, evaluate for mechanical venous obstruction that may be contributing to or causing the pelvic congestion:

• Assess for Nutcracker syndrome (compression of left renal vein between superior mesenteric artery and aorta), which can transmit increased pressure to pelvic veins via the left ovarian vein 1

• Evaluate for May-Thurner syndrome (compression of left common iliac vein by right common iliac artery), as the combination of gonadal vein reflux and nonthrombotic iliac vein lesions is associated with more severe symptoms 1

• Look for nonthrombotic iliac vein lesions (NIVL), which cause focal stenosis often not apparent on standard imaging but revealed on intravascular ultrasound 1

Initial Treatment Approach

Ovarian vein embolization is the primary treatment for confirmed pelvic congestion syndrome, with internal iliac vein embolization added when indicated. 1

Embolization Strategy:

• Transcatheter embolization of insufficient ovarian veins leads to complete relief of symptoms in 58.5% of cases and variable symptomatic relief in an additional 9.7% 2

• Internal iliac vein embolization in addition to ovarian vein embolization has been shown to be safe and effective, particularly when internal iliac vein reflux is demonstrated 1

• Bilateral embolization should be performed if bilateral ovarian vein insufficiency is documented on venography, though clinical outcomes are similar whether unilateral left or bilateral embolization is performed 2

• Technical success rate for ovarian vein embolization is 98%, with immediate complications occurring in only 4% of cases 2

Alternative or Adjunctive Treatment:

• Ultrasound-guided foam sclerotherapy (UGFS) of pelvic tributaries can be considered as an alternative or adjunct to embolization, with documented clinical symptomatic improvement 3

Special Considerations for Crohn's Disease

The presence of Crohn's disease does not contraindicate treatment of pelvic congestion syndrome, but requires attention to the following:

• Ensure any active luminal Crohn's disease is adequately treated with appropriate medical therapy (budesonide, conventional corticosteroids, azathioprine, 6-mercaptopurine, methotrexate, or infliximab) to reduce stool liquidity and pelvic inflammation 4

• Evaluate for perianal Crohn's disease, as the CT imaging should have included the perineum to facilitate detection of perianal involvement 4

• If perianal fistulas are present, these require drainage of any sepsis before initiating or continuing immunosuppressive treatment for Crohn's disease 4

• The enlarged pelvic veins are not a manifestation of Crohn's disease itself, though both conditions can coexist and require independent management 1

Follow-Up Protocol

Clinical follow-up should assess symptomatic relief at regular intervals following embolization:

• Initial follow-up at 1 month to assess immediate treatment response and identify any complications 2

• Continued monitoring at 3-6 month intervals during the first year, as long-term follow-up (mean 19.9 months) demonstrates sustained symptom relief in the majority of successfully treated patients 2

• Repeat pelvic venography if symptoms persist or recur, as incomplete resolution may indicate untreated contralateral ovarian vein insufficiency, internal iliac vein reflux, or coexisting mechanical obstruction (May-Thurner or Nutcracker syndrome) 5

• Duplex ultrasound surveillance can be used for non-invasive follow-up assessment of treated veins and detection of recurrent reflux 3

Common Pitfalls to Avoid

Failing to perform complete pelvic venous evaluation leads to treatment failure:

• Do not assume unilateral disease without bilateral ovarian and internal iliac venography, as incomplete evaluation is a common cause of persistent symptoms 5

• Do not overlook coexisting mechanical obstruction (May-Thurner, Nutcracker syndrome, or NIVL), which may require stenting in addition to embolization 1, 5

• Estrogen-containing medications may exacerbate symptoms through increased pelvic blood flow and nitric oxide-mediated smooth muscle relaxation, and should be reviewed 1

• Symptoms may subside after menopause due to decreased estrogen stimulation, which can inform long-term management discussions with premenopausal patients 1