COTW October 4th: A 57 year old with scrotal pain...

A 57 year old man presented to the ED with 3 days of unilateral testicular pain. No associated trauma.

Exam shows a large swollen R testicle that is exquisitely tender to palpation.

Bedside ultrasound as follows:

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The testicle is hypoechoic to normal testicular tissue and has a reactive hydrocele.

Note the absence of venous and arterial wave forms on pulse wave doppler.

Note the absence of venous and arterial wave forms on pulse wave doppler.

When compared with the contralateral testicle there is absent flow on power doppler.

When compared with the contralateral testicle there is absent flow on power doppler.

Patient was taken immediately to the OR, however despite de-torsion, orchiectomy and orchipexy was performed.

Learning points:

Know what a normal testicle looks like. The testicle should be homogeneous and have the echo texture of liver/thyroid. See below:

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ALWAYS COMPARE BOTH SIDES!

Use power doppler and pulse wave doppler to compare flow and evaluate for both venous and arterial pulsations.

Start by using power doppler and compare both testes, then use pulse wave doppler in these areas to get your waveforms.

Arterial waveform (left) Venous (right) (Radiopaedia.org)

Arterial waveform (left) Venous (right) (Radiopaedia.org)

Then look for secondary signs such as scrotal wall thickening, reactive hydrocele, and asymmetry in size and echogenicity.

COTW September 13th: A 75 y/o F with RLQ pain for about a week

The patient comes in with marked RLQ tenderness, nausea, GI upset, steadily getting worse… so you put a probe on…

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Notice that mucosal structure with some surrounding fluid… so you keep scanning…

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That’s A LOT of fluid! What is it? Could it be an Appy?

First, let’s review acute appendicitis ultrasound:

  1. Start on the point of maximal tenderness using the linear transducer and scan through the entire RLQ.

  2. Search for the aperistaltic, non-compressible, blind ended structure.

  3. Measure at the greatest diameter, > 6mm suggests appy

  4. Surrounding fluid collection gives it the classic, target appearance on axial section

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So… did our patient have appendicitis? Why was it different?

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Diagnosis: Perforated, acute appendicitis with an abscess

Key differences between perforated and non-perforated appy:

  1. Larger fluid collection that is not just closely surrounding the appy

  2. Mucosal surfaces may appear closer to each other, or even come in contact, as the inner fluid has leaked out

  3. Irregular appearance, not showing classic target shape on axial view

COTW September 4th: A 90 year old man with chest pain.

This is a case of a 90 year old male with abrupt onset chest pain radiating to his back. He was mildly hypertensive and with a normal EKG.

Bedside echo as follows:

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Parasternal long axis. Notice the dilated aortic root and intimal flap. This aortic root measured 4.98 cm.

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This is a high parasternal short axis view. You can also see the intimal flap here.

 Patient’s blood pressure was managed acutely, sent to CT scanner,  Thoracic surgery was consulted immediately.

Learning points:

 -Aortic root size >4 concerning for aortic root aneurysm and/or dissection

-Always evaluate for pericardial effusion when concerned for dissection or if there is evidence of inferior/right sided STEMI on EKG

-Utilize all your views (parasternal long axis, high parasternal short axis, subxiphoid). Suprasternal notch view is also a great way to pick up aortic dissection on POCUS.

COTW August 27th: A 34 year old female with pelvic pain and vaginal bleeding...

A 34 year old female presented to the ED 4 days prior with vaginal bleeding. UPT positive at home. Radiology department pelvic US performed, no IUP seen, beta HCG was 477.

She was discharged home with instructions for repeat studies in 48 hours. She returned to the ED  with abdominal cramping and persistent vaginal bleeding 4 days later. Repeat Beta HCG was 590.

POCUS performed:

On this first clip you see the uterus without any obvious gestational sac or sign of IUP. Notice that there is a moderate amount of free fluid within the pelvis surrounding the uterus.

On this first clip you see the uterus without any obvious gestational sac or sign of IUP. Notice that there is a moderate amount of free fluid within the pelvis surrounding the uterus.

On this next clip we see the adnexa and the first thing we see is a structure that appears to be an ovary with small follicles within it. However, adjacent to it you will notice that there is an echogenic mass that doesn’t quite appear to be part of the ovary itself.

On this next clip we see the adnexa and the first thing we see is a structure that appears to be an ovary with small follicles within it. However, adjacent to it you will notice that there is an echogenic mass that doesn’t quite appear to be part of the ovary itself.

This clip highlights the distinct areas and the mass that his highly suspicious for an ectopic pregnancy.

This clip highlights the distinct areas and the mass that his highly suspicious for an ectopic pregnancy.

She was seen by OB/GYN and opted to treat with Methotrexate and return to the ED for serial labs and follow-up. She presented again 2 days later with worsening symptoms and a larger adnexal mass. She was taken to the OR for operative management of the ectopic pregnancy. 

Learning points:

-Beta HCG normally doubles every 48 hours.

-ALWAYS ask about fertility treatments (risk of heterotopic pregnancy)

-To confirm IUP you need at minimum see a gestational sac ≥25mm with a yolk sac surrounded by ≥8mm of uterine tissue. Fetus and FHR are also great to see (in a gestational sac)

-When looking at the adnexa, be weary around the ovaries as ectopic pregnancies can look like follicles or cysts

COTW August 1st: A 3-year old male with intermittent abdominal pain for 3 days...

The patient was having 5-10 minute episodes of abdominal pain recurring about every 30 minutes, and had another one in the ED… so you put a probe on it…

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At the beginning of the clip, note the concentric structures separated by a thin, anechoic stripe forming a target shape. This indicates a cross-sectional view of bowel inside bowel.

By the end of the clip, the probe was rotated to obtain a longitudinal view showing the telescoping of bowel into bowel.

These findings are consistent with intestinal intussusception, which was later reduced with an enema.

Here’s another view highlighting the inner bowel:

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To perform this study, use the linear probe starting on RLQ and work your way up to the RUQ. Always remember that bowel should not be present within bowel. Usually you would find it by then, but if not, you can go across to the LUQ to the LLQ to trace the entire colon.

COTW June 25: An Elderly Lady with Epigastric Pain

It was the GI cocktail to end all GI cocktails.

An elderly lady with a history of peptic ulcer disease came in with epigastric pain that she reported as typical and for which she was requesting antacids.

Exam: 116/80, HR 96, O2 100%. Elderly lady in no distress with mild RUQ/epigastric tenderness.

Treating physician gave GI cocktail and patient got relief.

But then she suddenly became short of breath and had recurrence of her pain. A bedside ECHO was performed.

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What on earth!? A 5th heart chamber?
No, a thoracic aortic aneurysm.

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The parasternal short view also had more important information.

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Evidence of an intimal flap. Patient got a CTA of the chest which revealed a “descending thoracic aorta measuring up to 7.6 x 7.2 cm at the right atrium with dissection flap at the posterior aspect of the proximal descending thoracic aorta, extending to the aortic arch and the left subclavian artery.”

Suffice to say she was not discharged with PMD follow up.

Echo one, echo all chest and epigastric pain!

COTW: Right eye lacrimation and swelling

A 24y/o Male without any significant medical history presents to the ED with persistent tearing of the right eye and now recently noticed swelling near the medial canthus. The differential could include relatively benign conditions such as stye, blepharitis, or cellulitis. However, an Ultrasound found something more concerning.

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The above clip shows a normal appearing orbit, with what appears to be a fluid filled, septated, cystic structure medially. Note the fluid-fluid levels present as well. Orbital MRI was consistent with an Aneurysmal bone cyst of the ethmoid sinus. ENT was consulted and the patient was taken to the OR the following day.

This is a great example of how ultrasound lead to a quick diagnosis of an uncommon condition that could have easily been dismissed as something more benign on the first visit.

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:

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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.

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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.