Vascular emergencies & Appendicitis

Vascular emergencies

Question
?
1. 2. 3. 4. 2 3 4 5

Anatomy and Probe position

Transverse View

Transverse View

Longitudinal View

Coronal View view

Obstacles
Bowel gas Obesity

The cylinder tangent effect

Question
?
1. 2. 3. 4.

59M with hematuria and flank pain

SKHER AAA protocol

Any patient: age >= 50 y/o
Syncope / hypotension/dizziness and/or Abdominal / back / flank / groin pain

EUS Abdominal aorta evaluation

Subxiphoid area, longitudinal & transverse From just below diaphragm to bifurcation Epigastrium, SMA, and 3cm above bifurcation AAA: diameter more than 3cm (>=5cm, high risk)

59M with hematuria and flank pain AAA

Initial EUS 6 hours later

76M with abdominal pain AAA, impending rupture

65F with mid-abdominal pain Aortic dissection with flap

78M with AAA s/p grafting, Abdominal pain Ruptured AAA

69M with chest pain and shock

? 1. Hypovolemic shock 2. Obstructive shock 3. Cardiogenic shock 4. Septic shock

69M with chest pain and shock

Hemopericardium by aortic dissection

Hemopericardium by aortic dissection

84F IHCA during ERCP

91F with right thigh swelling for 3 d

? 1. Abscess 2. Pseudo-aneurysm 3. DVT 4. Tumor

91F with right thigh swelling for 3 d Pseudo-aneurysm

81F with left thigh ecchymosis AV fistula

59M with right arm painful swelling Pseudo-aneurysm

DVT

Clinical assessment model: Wells criteria

Active cancer (treatment ongoing or within previous 6 months or palliative) Paralysis, paresis or recent plaste, or immobilization of lower limbs Recently bedridden for 3 days or more, or major surgery < 4 weeks Localized tenderness along the DV system distribution Entire leg swollen Calf swelling > 3cm compared with asymptomatic leg (10cm below the tuberosity) Pitting edema 1 1 1 1 1 1 1

Collateral superficial veins (nonvaricose)

Previously documented DVT Alternative diagnosis as likely or greater than DVT Low probability Moderate probability High probability

1
1 -2 0 1-2 3

Question
?
1. 2. 3. 4. Doppler (thrombus) Doppler

EUS for DVT

Non-compression of the vessel
Inability to completely compress the vessels With proper pressure After ensuring good position

FYI:
Only complete compression r/o DVT Only the lack of total compression means DVT

Landmark for DVT Scan

Mid-point of inguinal ligment
Vessels: CFV & CFA Until CFV splits into DFV & SFV (Mid-thigh)

Popliteal fossa
Vessels: PV & PA The last 2 cm of PV and end just distal to the trifurcation the vein comes to the top in the pop

Contralateral leg scanning

Optional

Documentation
Dual-image feature: w/ & w/o compression

No complete compression
1. Presence of a clot 2. Inadequate pressure on the transducer

Methods to extend veins

Ideal transducer

Scanning technique

Position for femoral area

Effect of Compression

Popliteal area

DVT
EUS
Can tell you the presence or absence of proximal DVT Cant tell you
the presence or absence of distal DVT the cause of the pain if the US is normal

Two point compression approach Look for complete venous compression

Question: DVT ? (1) (2)

72F with left leg swelling and pain for 2 days; BT: 38.5

Question: DVT ? (1) (2)

DVT
Criteria: 1. Non-compressible vein 2. Echogenic thrombus

Question: DVT ? (1) (2) Mid-thigh DVT

59M, right leg swelling for 3 days DVT

Question: DVT ?
(1). L popliteal fossa (2). R popliteal fossa

64F with left leg pain and swelling, DVT ??

(1) (2) Lymphadenopathy

83M with left leg pain, DVT ?? (1) (2) Bakers cyst rupture

66M with right arm swelling Subclavian vein thrombosis

88F with abdominal pain

Volvulus ( Whirlpool sign)

77F with refractory abdominal pain

SMA occlusion

53F, cirrhosis with abdominal pain SMV thrombosis

Appendicitis

Graded compression technique

GI tract lesions on sonography

1. 2. 3. 4. 5. 6. (>4mm) (LN, fat, ascites)

Alvarado Score

Question
? 1. Blind-ended tubular structure 2. Non-compressible appendix 3. Diameter > 6mm 4. Dome sign 5. Appendicolith

Appendicitis
Diameter > 6mm (Cross section) Non-compressiblity of appendix Localized pain during compression with the transducer Alteration of the periappendiceal fat (echogenic & non-compressible fat) Obstruction of the lumen by an appendicolith Hypervascularizaion in color Doppler of appendix and surrounding fat
Eur Radiol. 2002;12:1748-61

Landmark of Appendix
RLQ
Iliac crest Psoas muscle Iliac vessels Cecum & A-colon

Appendiceal outer diameter for appendiceal mucocele VS appendicitis

Lien WC, AJEM (2006) 24, 801805

Cases

Cecum, Ileum and Appendicitis

Appendicolith

11M with appendicitis

27F, Pregnancy 14wks, Appendicitis

Lateral appendicits

Landmark

Ruptured appendicits

10M with peritonitis Ruptured appendicitis

14M with peritonitis Ruptured appendicitis

45F with RLQ pain

Ruptured retrocecal appendicitis

47M with RLQ pain

Ruptured appendicitis

66M with RLQ pain

Appendiceal mucocele

57F with mid-abdominal pain Appendicitis around umbilicus


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