COTW April 24: The Case of the...What on Earth is Going On with that RUQ?

A 65 year old F with a history of ESRD on HD came in with severe abdominal pain and hypotension that began during her dialysis session.

On exam she was tender, hypotensive 70/40, but not particularly ill appearing. A bedside ultrasound of the RUQ showed the following:

COTW Portal System Pneumatosis.gif

A CT scan demonstrated “gas throughout the portal vein and the portal venous system in the liver” as well as “areas of pneumatosis involving the small bowel some of which  demonstrate thickened wall” which were “findings concerning for small bowel ischemia.”

CTA of the abdomen showed no vascular explanation for small bowel ischemia. The patient went to the OR but was found not to have ischemic bowel.

The patient was admitted to the ICU and placed on pressor support, pain control and IVF hydration and was discharged a few days later.

The working theory is that she developed transient mesenteric ischemia secondary to hypovolemia due to fluid shifts related to her dialysis.

COTW: Just a little bit of an aortic dissection

Our ultrasound case of the week is a 56y/o male who presented to the ED for a second time with abdominal pain. It was sharp but mild, located in the lower midline. He looked great and work-up was initially negative. However, a quick bedside ultrasound of the aorta showed the below clip.

Distal aorta in long-axis.

Distal aorta in long-axis.

Its not obvious, but there seemed to be an irregularity in the lumen. This prompted a CTA showing a small dissection.

Aortic dissection is apparent as there are 2 separate enhancing lumens of the aorta.

Aortic dissection is apparent as there are 2 separate enhancing lumens of the aorta.

This patient was admitted, medically managed, and discharged 2 days later.

This is a great example of how a bedside ultrasound cinched a potentially serious diagnosis when all else seemed normal.

COTW March 21: The Short of Breath Teenager

A previously healthy 14 year old male came in with weakness and shortness of breath. He was running in high school gym class when he felt weak and dyspneic and had to lie down. He had had some diarrhea and vomiting for the past few days and a recent cold.

Exam and work-up:

HR 107, BP 82/61, O2 90%, RR 30, Oral Temp 97.6

Tachypneic, tachycardic, +bilateral rales with L > R, +Diaphoresis

WBCs: 15.8, Neutrophils 83%

Hb/Hct: 15.7/47.5

Glucose 222

Creatinine 1.18

Lactic Acid: 6.4

VBG pH 7.26 pCO2 50

AP CXR

Sepsis?

Patient given Antibiotics, 1L NS, 6L Oxygen Non Breather, but began to decompensate, bradying down, altered and lethargic. Patient was intubated and had peri-intubation arrest with CPR and code epi, ROSC, and started on epi drip.

A bedside ultrasound was performed.

COTW.gif

The bedside Echo showed global hypokinesis with plethoric IVC consistent with acute congestive heart failure. Note that if you thought this otherwise healthy pediatric patient was septic, his ECHO was not consistent with that diagnosis.

Troponin and BNP were resulted.
Trop: 15.3
BNP: 8

The patient was diagnosed with fulminant myocarditis and transferred to an appropriate referral center, where he was placed on ECMO for 3 days and made a full recovery.

COTW: A painful testicle

The patient is a 60 year old man with history of HTN, HLD and pre-DM who presented with fevers, chills, night sweats and worsening scrotal and testicular pain.

A bedside testicular ultrasound was performed:

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Note scrotal skin thickening, and dirty shadowing suggestive of subcutaneous air.

Diagnosis: Fournier’s gangrene.


OR report: extensive necrotizing fasciitis of entire right hemiscrotum, half of left hemiscrotum right pre-pubic area/base of penis and perineum with sparing of bilateral testicles.

Patient did well post-operatively. Cultures grew e. coli and bacteroides thetaiotaomicron and he was discharged on PO antibiotics four days later.