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Placenta previa

Placenta previa ultrasound case study

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Placenta previa Pathology

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Placenta previa ultrasound case study

Case Study Record

SN	Case Name	Report Line
1	Low-lying placenta	View Report Line
2	Marginal previa (Posterior)	View Report Line
3	Partial previa	View Report Line
4	Complet previa	View Report Line
5	-	-

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CASE–1
Low-Lying Placenta

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Clinical History

A 30-year-old pregnant female at 30 weeks of gestation presented with painless vaginal spotting. Obstetric ultrasound was requested to assess placental location and fetal well-being. There was no history of abdominal trauma or uterine contractions.

Ultrasound Findings

Ultrasound examination demonstrates a single live intrauterine fetus with appropriate cardiac activity. The placenta is located along the lower uterine segment, with the placental edge lying approximately 1.5 cm from the internal cervical os. The placenta does not cover the os. Placental echotexture is homogeneous without evidence of retroplacental hematoma or placental abruption. Amniotic fluid volume is within normal limits. Fetal biometry is appropriate for gestational age. The cervix appears closed and measures within normal limits.

Obstetric ultrasound. The placental edge is seen within 2 cm of the internal cervical os without covering it, consistent with a low-lying placenta.

Report Line

The placenta is implanted in the lower uterine segment with its inferior margin lying approximately 1.5 cm from the internal cervical os. There is no evidence of placenta previa, retroplacental hematoma, or placental abruption. The cervix remains closed. Findings are consistent with a low-lying placenta.

Impression

Features are consistent with a low-lying placenta, with the placental edge located within 2 cm of the internal cervical os but not covering it. No sonographic evidence of placenta previa or placental abruption.

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Recommendation

Follow-up ultrasound examination is recommended during the third trimester (usually at 32–36 weeks) to reassess placental position, as many low-lying placentas migrate upward with advancing pregnancy. Patients should seek immediate medical attention if vaginal bleeding, abdominal pain, or contractions occur. Delivery planning should be based on the final placental location and obstetric assessment.

Key Learning Points

• A low-lying placenta is defined as the placental edge lying within 2 cm of the internal cervical os without covering it.
• Transvaginal ultrasound is the gold standard for accurate assessment of placental location.
• Most low-lying placentas diagnosed during the second trimester migrate upward as pregnancy progresses.
• Placenta previa is diagnosed only when the placenta partially or completely covers the internal cervical os.
• Painless vaginal bleeding during the second or third trimester is the most common clinical presentation.
• Color Doppler evaluation helps assess placental vascularity and identify associated abnormalities when indicated.
• Repeat imaging at 32–36 weeks is recommended before determining the mode of delivery.

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CASE–2
Marginal Placenta Previa

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Clinical History

A 32-year-old gravida 2 para 1 female at 33 weeks of gestation presented with recurrent painless vaginal bleeding. Obstetric ultrasound was requested to evaluate placental location and fetal well-being. There was no history of abdominal trauma or uterine contractions.

Obstetric ultrasound. The placental edge extends up to the internal cervical os without covering it, consistent with marginal placenta previa.

Report Line

The placenta is located along the posterior wall of the lower uterine segment, with its inferior placental margin reaching the internal cervical os without extending beyond it. No evidence of retroplacental hematoma, placental abruption, or abnormal placental vascularity is identified. The cervix remains closed. Findings are consistent with posterior marginal placenta previa.

Impression

Sonographic features are consistent with posterior marginal placenta previa, with the placental edge reaching the internal cervical os without covering it. No sonographic evidence of placental abruption.

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CASE–3
Partial Placenta Previa

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Clinical History

A 29-year-old gravida 3 para 2 female at 34 weeks of gestation presented with recurrent episodes of painless bright-red vaginal bleeding. Obstetric ultrasound was requested to evaluate placental location and fetal well-being. There was no history of abdominal trauma or uterine contractions.

Obstetric ultrasound. The placenta extends over and partially covers the internal cervical os, consistent with partial placenta previa.

Report Line

The placenta is located in the lower uterine segment with placental tissue partially covering the internal cervical os. No retroplacental hematoma, placental abruption, or abnormal placental vascularity is identified. The cervix remains closed. Findings are consistent with partial placenta previa.

Impression

Sonographic features are consistent with partial placenta previa, with partial coverage of the internal cervical os. No evidence of placental abruption or other acute placental abnormality.

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CASE–4
Complete Placenta Previa

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Clinical History

A 35-year-old gravida 4 para 3 female at 35 weeks of gestation presented with recurrent episodes of painless profuse vaginal bleeding. She had a previous history of cesarean section. Obstetric ultrasound was requested to determine placental location and assess fetal well-being.

Obstetric ultrasound. The placenta completely overlies the internal cervical os, consistent with complete placenta previa.

Report Line

The placenta is located in the lower uterine segment and completely covers the internal cervical os. No evidence of retroplacental hematoma, placental abruption, or abnormal placental vascularity is identified. The cervix remains closed. Findings are consistent with complete placenta previa.

Impression

Sonographic features are consistent with complete placenta previa, with complete coverage of the internal cervical os. No sonographic evidence of placental abruption. This represents a high-risk obstetric condition.

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Nabothian Cyst

Nabothian Cyst ultrasound case study

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Reporting Panel

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Uterine Pathology

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USG

Nabothian Cyst ultrasound case study

Case Study Record

SN	Case Name	Report Line
1	Single Nabothian Cyst	View Report Line
2	Multiple Nabothian Cyst	View Report Line
3	-	-
4	-	-
5	-	-

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CASE–1
Single Nabothian Cyst

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Clinical History

A 36-year-old female presented with chronic pelvic pain and occasional vaginal discharge. Pelvic ultrasound was performed as part of the evaluation. There was no history of abnormal uterine bleeding or cervical malignancy.

Ultrasound Findings

Ultrasound examination demonstrates a well-defined, thin-walled, anechoic cystic lesion measuring approximately 8–15 mm within the cervical stroma. The lesion shows posterior acoustic enhancement without internal septations, mural nodules, or internal vascularity on Color Doppler. The remainder of the cervix appears normal. The uterus and bilateral ovaries are unremarkable. No pelvic free fluid is identified.

Ultrasound of the cervix. A well-defined anechoic cyst is seen within the cervical stroma demonstrating posterior acoustic enhancement and no internal vascularity, consistent with a single Nabothian cyst.

Report Line

A solitary well-defined anechoic thin-walled cyst measuring approximately 8 × 7 mm is identified within the cervical stroma, demonstrating posterior acoustic enhancement without internal echoes, septations, mural nodules, or internal vascularity on Color Doppler. No suspicious cervical mass or associated pelvic abnormality is seen. Findings are consistent with a benign Nabothian cyst.

Impression

Features are consistent with a single benign Nabothian cyst of the cervix. No sonographic evidence of cervical neoplasm or other significant pelvic pathology.

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Recommendation

Nabothian cysts are common benign retention cysts of the cervix and usually require no treatment. Clinical follow-up is recommended only if the lesion is unusually large, symptomatic, atypical in appearance, or associated with abnormal cervical examination findings. Routine gynecological evaluation and cervical screening should continue as clinically indicated.

Key Learning Points

• Nabothian cysts are benign mucus retention cysts resulting from obstruction of endocervical glands.
• Ultrasound typically demonstrates a small, well-circumscribed anechoic cyst within the cervical stroma.
• Posterior acoustic enhancement and absence of internal vascularity are characteristic features.
• Most Nabothian cysts are incidental findings and require no treatment.
• Large or atypical cystic cervical lesions should be differentiated from cervical tunnel clusters, Gartner duct cysts, cervical endometriosis, or cystic cervical neoplasms.
• Correlation with pelvic examination and cervical screening is recommended when clinically indicated.
• Routine follow-up imaging is generally unnecessary for a typical asymptomatic Nabothian cyst.

Report Line

Multiple well-defined anechoic thin-walled cysts are identified within the cervical stroma, the largest measuring approximately 8 × 7 mm. The cysts demonstrate posterior acoustic enhancement without internal echoes, septations, mural nodules, or internal vascularity on Color Doppler. No suspicious cervical mass or associated pelvic abnormality is seen. Findings are consistent with multiple benign Nabothian cysts.

Impression

Features are consistent with multiple benign Nabothian cysts of the cervix. No sonographic evidence of cervical neoplasm or other significant pelvic pathology.

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Diffuse uterine adenomyosis

Diffuse uterine adenomyosis ultrasound case study

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Reporting Panel

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Uterine Pathology

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USG

Diffuse uterine adenomyosis ultrasound case study

CASE–1

Clinical History

A 38-year-old multiparous female presented with progressively worsening dysmenorrhea, chronic pelvic pain, menorrhagia, and pelvic heaviness over the past several years. She was referred for pelvic ultrasound to evaluate suspected adenomyosis.

Ultrasound Findings

Ultrasound examination demonstrates a diffusely enlarged globular uterus measuring approximately 11.2 × 6.8 × 7.1 cm. The myometrium is diffusely heterogeneous with coarse echotexture and asymmetric thickening of the posterior myometrial wall. Multiple tiny intramyometrial cysts measuring approximately 2–5 mm are identified. Prominent echogenic subendometrial linear striations extending into the myometrium and fan-shaped posterior acoustic shadowing are noted. The endometrial-myometrial junction (junctional zone) appears indistinct. No discrete leiomyoma is identified. Color Doppler demonstrates diffuse translesional vascularity throughout the affected myometrium. The endometrium measures 8.6 mm and appears regular. Both ovaries are unremarkable. No adnexal mass or free pelvic fluid is identified.

Transabdominal pelvic ultrasound. Diffuse globular enlargement of the uterus with heterogeneous myometrium, asymmetric posterior myometrial wall thickening, subendometrial echogenic striations, tiny myometrial cysts, and fan-shaped acoustic shadowing, compatible with diffuse uterine adenomyosis.

Report Line

The uterus is diffusely enlarged with a globular configuration, measuring approximately 11.2 × 6.8 × 7.1 cm. The myometrium demonstrates diffuse heterogeneous echotexture with asymmetric posterior wall thickening, multiple tiny intramyometrial cysts, echogenic subendometrial linear striations, fan-shaped posterior acoustic shadowing, and an indistinct endometrial-myometrial junction. The endometrium measures 8.6 mm. Sonographic findings are highly suggestive of diffuse uterine adenomyosis.

Impression

Sonographic features are consistent with diffuse uterine adenomyosis.

Recommendation

Correlation with the patient's clinical symptoms is recommended. Gynecological consultation is advised for treatment planning. MRI pelvis may be considered when the diagnosis is uncertain or for preoperative mapping. Management options include hormonal therapy, levonorgestrel-releasing intrauterine system (LNG-IUS), uterine artery embolization in selected patients, or hysterectomy in women with severe symptoms who have completed childbearing.

Key Learning Points

• Diffuse adenomyosis results from ectopic endometrial glands and stroma within the myometrium, producing diffuse uterine enlargement.
• The classic ultrasound appearance includes a globular bulky uterus with heterogeneous myometrium.
• Characteristic findings include asymmetric myometrial wall thickening, tiny myometrial cysts, echogenic linear striations, fan-shaped acoustic shadowing, and an indistinct junctional zone.
• Color Doppler typically demonstrates diffuse translesional vascularity rather than peripheral vascularity seen with fibroids.
• The principal differential diagnoses include diffuse leiomyomatosis, multiple fibroids, and focal adenomyoma.
• MRI is the most accurate imaging modality when ultrasound findings are equivocal or for surgical planning.
• Diffuse adenomyosis commonly presents with dysmenorrhea, menorrhagia, chronic pelvic pain, and infertility in women of reproductive age.

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Uterine scar endometriosis

Uterine scar endometriosis ultrasound case study

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Reporting Panel

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Uterine Pathology

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Uterine scar endometriosis ultrasound case study

CASE–1

Clinical History

A 33-year-old female with a previous lower segment cesarean section (LSCS) presented with progressive dysmenorrhea, chronic pelvic pain, and intermittent abnormal uterine bleeding. She was referred for pelvic ultrasound to evaluate a suspected uterine scar lesion.

Ultrasound Findings

Ultrasound examination demonstrates a well-defined heterogeneous hypoechoic lesion involving the anterior lower uterine segment at the site of the previous cesarean section scar. The lesion extends into the adjacent myometrium with indistinct margins. Multiple tiny internal echogenic foci are noted. Color Doppler demonstrates mild to moderate internal vascularity. The remainder of the myometrium is unremarkable without focal fibroids. The endometrium measures 9.5 mm in thickness and appears regular. No pelvic abscess or free fluid is identified.

TVS pelvic ultrasound. A heterogeneous hypoechoic lesion is demonstrated within the previous cesarean section scar in the lower uterine segment, compatible with uterine scar endometriosis.

Report Line

A well-defined heterogeneous hypoechoic lesion measuring approximately 25 × 18 × 16 mm is identified within the anterior lower uterine segment at the site of the previous cesarean section scar. The lesion extends into the adjacent myometrium and demonstrates mild internal vascularity on Color Doppler with a few internal echogenic foci. A focal communication with the anterior endometrial lining through the cesarean scar defect is noted. No significant surrounding fluid collection is identified. Sonographic findings are highly suggestive of uterine cesarean scar endometriosis.

Impression

Sonographic features are consistent with uterine scar endometriosis involving the previous cesarean section scar. No evidence of pelvic abscess or associated adnexal inflammatory collection.

Recommendation

Correlation with the patient's history of previous cesarean section and cyclical pelvic pain is recommended. MRI pelvis may be performed to assess the depth of myometrial involvement and exclude associated adenomyosis if clinically indicated. Gynecological consultation is advised. Surgical excision with histopathological examination remains the definitive treatment.

Key Learning Points

• Uterine scar endometriosis is a rare form of cesarean scar endometriosis involving the myometrium of the lower uterine segment.
• Patients typically present with cyclical pelvic pain, dysmenorrhea, and abnormal uterine bleeding.
• Ultrasound commonly demonstrates a heterogeneous hypoechoic lesion within the cesarean scar with internal vascularity.
• The differential diagnosis includes cesarean scar defect (isthmocele), scar hematoma, adenomyosis, fibroid, and cesarean scar pregnancy.
• MRI provides superior assessment of lesion extent and myometrial infiltration.
• Complete surgical excision is the treatment of choice.
• Histopathological examination confirms the diagnosis.

Reactive uterine enlargement associated with PID

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Bulky uterus
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Reactive PID

Bulky uterus or Reactive PID ultrasound case study

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Uterine Pathology

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USG

Bulky uterus or Reactive PID ultrasound case study

CASE–1

Clinical History

A 34-year-old female presented with lower abdominal pain, fever, abnormal vaginal discharge, and pelvic tenderness. She was referred for pelvic ultrasound to evaluate suspected pelvic inflammatory disease (PID). There was no history suggestive of uterine fibroids or adenomyosis.

Ultrasound Findings

Ultrasound examination demonstrates a mildly bulky anteverted uterus measuring approximately 12.7 × 5.9 × 5.0 cm (estimated uterine volume 197 mL). The myometrium appears mildly heterogeneous without any focal myometrial mass or fibroid. The endometrial thickness measures approximately 9.5 mm and appears regular. Mild diffuse reactive enlargement of the uterus is noted. Mild inflammatory changes are present within the pelvis, with a small amount of free fluid in the pouch of Douglas. No retained products of conception or intrauterine collection is identified. Both ovaries are visualized with preserved morphology and vascularity.

Transabdominal pelvic ultrasound. Mildly enlarged (bulky) uterus measuring approximately 12.7 × 5.9 × 5.0 cm with mildly heterogeneous myometrium. Endometrial thickness measures 9.5 mm. The findings are compatible with reactive uterine enlargement associated with pelvic inflammatory disease (PID).

Report Line

Mild bulky uterus measuring approximately 12.7 × 5.9 × 5.0 cm (estimated uterine volume 197 mL) with mildly heterogeneous myometrial echotexture. Endometrial thickness measures 9.5 mm. No focal myometrial lesion is identified. Mild reactive inflammatory enlargement of the uterus is noted in association with pelvic inflammatory changes, consistent with PID-associated bulky uterus.

Impression

Reactive uterine enlargement associated with pelvic inflammatory disease (PID).

Recommendation

Clinical correlation with symptoms, pelvic examination, and inflammatory markers is recommended. Appropriate antibiotic therapy should be considered according to institutional PID guidelines. Follow-up pelvic ultrasound after completion of treatment may be performed to document resolution of the reactive uterine enlargement and associated inflammatory changes.

Key Learning Points

• A mildly bulky uterus is a non-specific ultrasound finding and may occur as a reactive change in PID.
• Reactive uterine enlargement is characterized by diffuse mild uterine enlargement without a focal myometrial mass.
• The myometrium may appear mildly heterogeneous due to inflammatory edema.
• The endometrium may be normal or mildly thickened depending on associated endometritis.
• Associated ultrasound findings of PID include pelvic free fluid, salpingitis, hydrosalpinx, pyosalpinx, tubo-ovarian complex, or tubo-ovarian abscess.
• Color Doppler may demonstrate increased myometrial vascularity in active inflammation.
• Correlation with clinical findings and laboratory investigations is essential, as ultrasound findings alone are not diagnostic of PID.

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LSCS
Endometriosis

Endometriosis ultrasound case study

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Reporting Panel

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LSCS Pathology

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LSCS endometriosis ultrasound case study

CASE–1

Clinical History

A 32-year-old female presented with a painful swelling in the anterior lower abdominal wall over the previous lower segment cesarean section (LSCS) scar. The pain was cyclical, increasing during menstruation. The patient was referred for ultrasound evaluation to assess the palpable scar lesion.

Ultrasound Findings

Ultrasound examination demonstrates a well-defined irregular heterogeneously hypoechoic solid lesion within the anterior abdominal wall involving the subcutaneous tissue and rectus sheath at the site of the previous LSCS scar. ternal scattered echogenic foci and mild posterior acoustic attenuation are noted. Color Doppler demonstrates mild to moderate internal vascularity. Mild surrounding fibrotic changes are present. No liquefaction, abscess, or fascial defect is identified. No evidence of incisional hernia is seen.

Ultrasound of the anterior abdominal wall. A heterogeneously hypoechoic vascular soft tissue lesion is demonstrated within the previous LSCS scar, consistent with scar endometriosis.

Report Line

A well-defined heterogeneously hypoechoic soft tissue lesion is noted within the anterior abdominal wall at the site of the previous LSCS scar, measuring approximately 35 × 26 mm. The lesion demonstrates mild to moderate internal vascularity on Color Doppler with surrounding fibrotic changes. No cystic degeneration, abscess, or incisional hernia is identified. Sonographic findings are highly suggestive of abdominal wall (LSCS scar) endometriosis.

Impression

Features are consistent with abdominal wall endometriosis involving the previous LSCS scar. No sonographic evidence of abscess formation or associated incisional hernia.

Recommendation

Correlation with the history of cyclical pain and previous cesarean section is recommended. Surgical consultation for complete excision is advised. Histopathological examination following excision is recommended for definitive diagnosis. MRI may be considered for preoperative assessment if deep fascial or muscular involvement is suspected.

Key Learning Points

• Scar endometriosis is a rare complication following cesarean section or other gynecological surgeries.
• The typical clinical presentation is a painful palpable mass at the surgical scar with cyclical worsening during menstruation.
• Ultrasound usually demonstrates a heterogeneously hypoechoic solid lesion with internal vascularity.
• Differential diagnoses include suture granuloma, desmoid tumor, hematoma, abscess, incisional hernia, and soft tissue neoplasm.
• MRI is useful for evaluating the extent of disease before surgery.
• Complete surgical excision with clear margins is the treatment of choice and minimizes recurrence.
• Histopathological examination remains the gold standard for definitive diagnosis.

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Acute appendicitis

Acute appendicitis ultrasound case study

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Appendix Pathology

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USG

Acute appendicitis ultrasound case study

CASE–1

Clinical History

A 24-year-old patient presented with acute right lower quadrant abdominal pain, fever, nausea, vomiting, and loss of appetite. On clinical examination, there was localized tenderness at McBurney's point with guarding. The patient was referred for abdominal ultrasound to evaluate suspected acute appendicitis.

Ultrasound Findings

Ultrasound examination demonstrates a blind-ending, non-compressible tubular structure arising from the cecum in the right iliac fossa measuring approximately 8.5 mm in maximal outer diameter. The appendiceal wall is thickened with preserved mural stratification. Increased periappendiceal echogenic fat is noted, consistent with surrounding inflammatory changes. Color Doppler demonstrates increased mural vascularity (hyperemia). A small amount of periappendiceal free fluid is present. No appendicolith, periappendiceal abscess, perforation, or phlegmon is identified.

Ultrasound of the right iliac fossa. A non-compressible blind-ending tubular structure measuring greater than 6 mm with periappendiceal inflammatory fat changes and increased Color Doppler vascularity is demonstrated, consistent with acute appendicitis.

Report Line

A blind-ending, non-compressible tubular structure arising from the cecum measures approximately 8.5 mm in maximal diameter with mural thickening and increased Color Doppler vascularity. Mild periappendiceal inflammatory fat changes and a small amount of adjacent free fluid are present. No appendicolith, periappendiceal abscess, perforation, or phlegmon is identified. Sonographic findings are consistent with acute uncomplicated appendicitis.

Impression

Features are consistent with acute uncomplicated appendicitis with associated mild periappendiceal inflammatory changes. No sonographic evidence of perforation or periappendiceal abscess.

Recommendation

Urgent surgical consultation is recommended. Correlation with clinical findings and laboratory investigations (CBC, CRP, and inflammatory markers) is advised. If ultrasound findings are equivocal or complications are suspected, contrast-enhanced CT abdomen and pelvis (or MRI in pregnancy) should be considered for further evaluation. Prompt surgical management should be guided by the treating surgeon.

Key Learning Points

• The normal appendix measures ≤6 mm in maximal outer diameter and is compressible.
• Acute appendicitis typically appears as a non-compressible blind-ending tubular structure measuring >6 mm.
• Increased periappendiceal fat echogenicity and Color Doppler hyperemia are important secondary signs of inflammation.
• An appendicolith appears as an echogenic focus with posterior acoustic shadowing and increases the risk of perforation.
• Periappendiceal fluid, abscess, phlegmon, or loss of mural integrity suggests complicated appendicitis.
• Ultrasound is the preferred first-line imaging modality in children, young adults, and pregnant patients.
• CT abdomen has the highest diagnostic accuracy when ultrasound findings are inconclusive or complications are suspected.

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Intestinal ascariasis

Intestinal ascariasis ultrasound case study

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Reporting Panel

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Colun Pathology

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USG

Intestinal ascariasis ultrasound case study

CASE–1

Clinical History

A 28-year-old patient presented with intermittent colicky abdominal pain, abdominal distension, nausea, vomiting, poor appetite, and passage of worms in the stool. The patient was referred for abdominal ultrasound to evaluate suspected intestinal ascariasis and exclude bowel obstruction.

Ultrasound Findings

Ultrasound examination demonstrates multiple elongated linear echogenic tubular structures within the lumen of the small bowel, some showing a central longitudinal anechoic tube ("inner tube" or "railway track" sign), consistent with Ascaris lumbricoides. Mild fluid-filled bowel loops are present without significant bowel wall thickening. No evidence of bowel obstruction, bowel perforation, intussusception, free intraperitoneal fluid, or localized abscess is identified. No worms are visualized within the biliary tree on the current examination.

Ultrasound of the small bowel. Multiple elongated echogenic tubular structures with a central anechoic channel ("railway track" or "inner tube" sign) are visualized within the bowel lumen, consistent with intestinal ascariasis.

Report Line

Multiple elongated echogenic tubular structures with central longitudinal anechoic channels are demonstrated within the lumen of the small bowel, consistent with intestinal Ascaris lumbricoides infestation. No evidence of bowel obstruction, perforation, intussusception, free intraperitoneal fluid, or localized abscess is identified. No sonographic evidence of biliary ascariasis is seen on the current examination.

Impression

Features are consistent with intestinal ascariasis (Ascaris lumbricoides infestation) without sonographic evidence of bowel obstruction or other acute complications.

Recommendation

Clinical correlation and stool examination for ova and parasites are recommended. Appropriate antihelminthic therapy (e.g., albendazole or mebendazole) should be initiated as clinically indicated. Follow-up ultrasound may be considered if symptoms persist or if complications such as bowel obstruction or biliary migration are suspected.

Key Learning Points

• Ascaris lumbricoides is the most common intestinal helminth affecting humans.
• On ultrasound, intestinal worms appear as elongated echogenic tubular structures with a central anechoic tube ("inner tube" or "railway track" sign).
• Multiple worms may produce the "bag of worms" appearance within dilated bowel loops.
• Ultrasound is useful for detecting living worms and associated complications such as bowel obstruction, intussusception, or biliary ascariasis.
• Stool microscopy remains the standard laboratory test for confirming intestinal ascariasis.
• Albendazole or mebendazole are the first-line antihelminthic treatments.
• Heavy worm infestation may lead to intestinal obstruction, volvulus, perforation, pancreatitis, or biliary obstruction requiring urgent management.