VOTW: A real gut-wrenching situation!

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Hello all! This week’s VOTW is brought to you by yours truly!

Hospital course

83 y/o F with PMH esophageal hernia presented to the ED with 2 days of abdominal fullness, nausea, and vomiting. Last bowel movement was 2 days ago. Bedside ultrasound was done.

This is small bowel. How do we know this? Note the small finger-like projections from the inner wall (yellow arrows). These are called plicae circulares, which are  mucosal folds of the small intestine. Also note that the bowel diameter is dilated up to 3.2 cm (blue arrow).

Note the transverse view of the small bowel below the stomach. The bowel wall appears thicker than normal, measuring 0.88 cm. Also note that the stomach itself appears very dilated!

In the clip above, we can see multiple loops of dilated small bowel. We can see hyperechoic specs of intestinal contents within the bowel making a “to-and-fro” motion instead of normal unidirectional peristalsis.

In the clip above, we can see dilated small bowel with no movement of the intestinal contents at all!

Case Conclusion

The patient was found to have a small bowel obstruction with an incarcerated femoral hernia on CT imaging. NG tube was placed in the ED and patient was admitted for surgical intervention.

Characteristic Findings of SBO

·       In normal small bowel, the regular bowel diameter is < 2.5 cm and we expect to see normal peristalsis with unidirectional flow.

·       A small bowel obstruction on ultrasound will show multiple loops of bowel with a diameter > 2.5 cm. The intestinal contents will appear to move back and forth with “to-and-fro” movement. Sometimes the distal obstruction will prevent the intestinal contents from moving at all!

·       A small bowel obstruction will also lead to bowel wall edema, which causes a wall thickness > 4 mm. The bowel wall edema and dilated diameter will make the intestinal folds or plicae circulares appear more prominent, leading to the “key board” sign seen in the image above.

 

Happy scanning!

Sono team

 

Resources to review:

·       https://coreultrasound.com/small-bowel-obstruction/

·       https://www.emdocs.net/us-probe-ultrasound-for-small-bowel-obstruction/

·       https://www.acep.org/sonoguide/advanced/gi---bowel-obstruction

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VOTW: The chamber that bounced back!

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Hello all! Check out this week’s VOTW by yours truly!

Hospital course

A 60 y/o M with extensive PMH including ESRD on dialysis and CHF presented to the ED complaining of generalized weakness and SOB. He was hypotensive and anemic. Bedside TTE was performed.

In both parasternal and short axis views seen above, there is a circumferential pericardial effusion surrounding the entire heart.

Parasternal long view: We can see the RV collapse during diastole. How do we know this is diastole? Note that we can see the opening of both the mitral valve and the tricuspid valve to allow for ventricular filling, which occurs during the diastolic phase of cardiac contraction. See clip #1 to see a video of this RV diastolic collapse.

Short axis view: Here we see an example of ‘trampoline sign’, which is the characteristic bouncing motion of the RV. In the image above, we see inversion of the RV wall during diastole (arrow). How do we know this is diastole? Again, note that we can see the opening of the mitral valve in the LV when the RV wall inverts. See clip #2 to see a video of the ‘trampoline sign’.

IVC: In clip #3, we see a very distended plethoric IVC without respiratory variation.

Case Conclusion

The patient was found to have a large pericardial effusion with tamponade. He was stabilized and admitted to cardiology for a pericardial window.

Characteristic Findings of Cardiac Tamponade on POCUS

·       The transition from a pericardial effusion to tamponade is due to the rate of fluid accumulation within the pericardial sac, not the total volume of effusion. The right heart is a low-pressure system and collapses when it is unable to accommodate the acute increase in pressure seen when fluid quickly fills the surrounding pericardial sac.  

·       Thus, the earliest sonographic finding of cardiac tamponade is RA collapse during systole. This is typically followed by RV collapse during diastole, which has both high sensitivity and specificity for cardiac tamponade.

·       A non-collapsible plethoric IVC is the most sensitive sign of cardiac tamponade.

 

Happy scanning!

Sono team

 

Resources to review:

·       https://coreultrasound.com/pericardial-tamponade/

·       https://www.acep.org/emultrasound/newsroom/may-2024/cardiac-tamponade

·       https://www.aliem.com/differentiating-pericardial-effusion-tamponade-ultrasound/

·       https://www.emra.org/emresident/article/us-cardiac-tamponade

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VOTW: Tube-y or not Tube-y: Two Cases of Ectopic Pregnancy

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Case 1

33-year-old female G3P1, LMP 7 weeks ago, with a history of ectopic pregnancy, which was medically managed, presenting with 1 day of vaginal bleeding. Beta-hCG 5200. 

Transvaginal pelvic ultrasound showed no definitive intrauterine pregnancy and a cystic structure in the left adnexa by the ovary.

In the perinatal unit, ultrasound by MFM confirmed an ectopic pregnancy with a visible fetal heart rate. The patient underwent laparoscopy and salpingectomy that showed a dilated left fallopian tube and had a small amount of intraoperative blood loss. 


Case 2

36-year-old female G4P2, LMP 3 weeks ago, presenting with lower abdominal pain after a bowel movement, followed by vaginal bleeding. Beta-hCG was 230. 

Transvaginal pelvic ultrasound showed no definitive intrauterine pregnancy and a moderate to large amount of free fluid.

The patient underwent diagnostic laparoscopy with salpingectomy. 300 mL of hemoperitoneum was found intraoperatively, and the patient was diagnosed with a left ruptured tubal ectopic pregnancy.

Ectopic pregnancy on ultrasound

Approach

  • Start with the curvilinear probe and switch to the endocavitary probe if better resolution is needed

  • In a patient of childbearing age with abdominal pain and hypotension, start with a FAST exam to look for free fluid in Morison’s pouch

Findings suggestive of ectopic pregnancy

  • Empty uterine cavity or intrauterine fluid without a yolk sac

  • Abdominal free fluid 

  • A “tubal ring” appearance, an echogenic ring that surrounds an unruptured ectopic pregnancy (n.b. this can be mimicked by a normal corpus luteum). See structure marked by arrow in image above. 

  • Less than 5 mm of myometrium surrounding an eccentrically located gestational sac. This is a type of ectopic pregnancy called an interstitial pregnancy.

References

Happy scanning!

US team