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Lower abdominal echo

Scenario
25 y/o female C/O: acute low abdominal pain w/ cold sweating, VAS: 8/10 BP: 60/40 mmHg; HR: 130 bpm Menstruation: 2nd day Your impression ? Next step ?

2008 ACEP EUS guidelines

Describe the relevant local anatomy of pelvic cavity Describe the role of focused US in first-trimester pregnancy pain and bleeding. Understand the role of US and quantitative -hCG in a clinical algorithm for firsttrimester pregnancy pain and bleeding. Understand the differential diagnosis of early pregnancy including intrauterine pregnancy, embryonic demise, molar pregnancy, ectopic pregnancy, and indeterminate classes. Recognize the relevant focused findings and pitfalls when evaluating for early intrauterine pregnancy and ectopic pregnancy. Early embryonic structures Location of embryonic structures in pelvis Findings of ectopic pregnancy Pseudogestational sac Adnexal masses

Role of EUS for OB/GYN

Identify an IUP Establish fetal viability Hemodynamic instability in a female patient Trauma and pregnancy Localization of IUD/foreign body Identify sources of pelvic pain and bleeding in pregnant & non-pregnant patients

1st choice for emergency physician Use a lower frequency transducer: 3.5 5 mHz Better penetration, larger field of view It should be the initial imaging window to assess for
Advanced IUP Fibroids/masses Pelvic fluid

Trans-abdominal US

The bladder should be full to provide an acoustic window

Transvaginal US
Use a higher frequency transducer: 6.0-7.5mHz Provides optimal imaging of:
Endometrium Myometrium Cul-de-sac Ovaries

A full bladder is not necessary for this approach Is usually better tolerated by patients

Normal Pelvic Anatomy

Trans-Abdominal Scan

Normal Pelvic Scan

TVS: Sagittal View

Pelvic Scan (TVS)

TAS versus TVS

Pelvic Sagittal View

US Findings in IUP
Gestational sac Double decidual sac sign (DDSS) Yolk sac Embryo Cardiac activity

Intradecidual Sign

Gestational Sac
Anechoic area within the uterus surrounded by two bright echogenic rings
Decidua vera (the outer ring) Decidua capsularis (the inner ring)

This is referred to as the double decidual sac sign (DDSS)

Double Decidual Sign

Yolk Sac
First embryonic structure that can be detected sonographically Visualized approximately 5-6 weeks after the last menstrual period Bright, ring like structure within the GS Should be readily seen when the GS sac is greater than 10 mm (using EVS)

Yolk Sac

Embryo & Yolk Sac

Intrauterine embryo & yolk sac

Intrauterine fetus and yolk sac & amnion

A Fetal Heart Beat

An important prognostic indicator The rate of spontaneous abortion is extremely low (2- 4%) after the detection of normal embryonic cardiac activity The normal fetal heart rate in early pregnancy is 112-136

43F complained low abdominal pain

What do you see ?

Ectopic pregnancy
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Ectopic Pregnancy
2% of all pregnancies, 7-13% of those who present with pain or bleeding Incidence quadrupled in last 20 years 50% were missed before widespread use of ultrasound Still the #1 cause of maternal death in 1st trimester

Rule-out Ectopic Pregnancy (saves time and money)

Find an IUP Chance of both IUP and EP is 1/8000 As high as 1/100 if pt takes fertility agents

-hCG Levels
Correlate roughly with gestational age Older algorithms relied on -hCG One level means almost nothing Serial levels are helpful 40% ectopics have a -hCG level <1000

Discriminatory Zone
Def:
The level of -hCG at which findings of an IUP are expected on sonography

Titinalli 7th ed.

TVS 1500 mIU/mL; TAS 6000 mIU/mL

Rosen
TVS 3000 mIU/mL; TAS 6500 mIU/mL

-hCG >discriminatory zone and empty uterus is EP until proven otherwise

 Ruptured ectopic pregnancy Definite ectopic pregnancy

Sonographic Spectrum of EP

Extrauterine empty gestational sac Adenexal mass Pseudogestational sac Empty uterus

Ectopic Pregnancy

Empty uterus & free fluid in CDS

Empty Uterus & Complex fluid in CDS

Empty Uterus & Free fluid in CDS & hepatorenal space

Complex adnexal mass

39F_33wk + ABD pain

Molar pregnancy

Estimation of GA

Pregnancy Dating Crown Rump Length (CRL)

Biparietal Diameter

Femur Length

Fetal Heart Rate Determination

Location of appendix

Pregnancy 18wks & 30wks & Appendicitis

 Determining the etiology of abdominal pain pelvic organs or other etiology Hemorrhagic ovarian cyst Ovarian torsion Ovarian hyperstimulation syndrome (OHSS) Tubo-ovarian abscess Fibroid (Leiomyoma)

Main Goals in Non-pregnant Patients

Ruptured corpus luteum cyst

16F with low abdominal pain Pregnancy test: negative

What do you see ?

Ruptured ovarian cyst with internal bleeding

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OHSS

18F with low abdominal pain

What do you see ?

Pelvic Tumor
51

16F with severe low abdominal pain

What do you see ?

Hematometria
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47F with low abdominal pain

What do you see ?

Teratoma
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39F with fever and low abdominal pain

What do you see ?

TOA & Pyosalpinx

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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

Cecum, Ileum and Appendicitis

Appendicitis with obvious cecum and ileum

Appendicolith

Appendicitis with appendicolith

Landmark

Ruptured appendicits

10M with low abdominal pain

What do you see ?

Ruptured appendicitis
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14M with low abdominal pain

What do you see ?

Ruptured appendicitis with abscess and ileus

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47M with RLQ and low abdominal pain

What do you see ?

Ruptured appendicitis
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27F, pregnancy at 14 wk RLQ pain

What do you see ?

Appendicitis
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Colon

21M with RLQ pain

What do you see ?

Cecal diverticulitis
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? 1. Corona sign 2. Target sign 3. Curtain sign 4. Dome sign 5. Veiled Kidney sign

21M with RLQ pain Cecal diverticulitis

Dome sign: acute colonic diverticulitis

J Clin Ultrasound. 2000;28:340-6.

Right-sided diverticulitis in a 32-year-old woman with right lower quadrant pain and fever

O'Malley, M. E. et al. Radiographics 2003;23:59-72

Copyright Radiological Society of North America, 2003

48M with right abdominal pain

A-colon diverticulitis

18M with RLQ pain

Cecal diverticulitis

25F with LLQ pain

S-colon diverticulitis

26F with RUQ pain

A-T colon junction diverticulitis

32M with RLQ pain

Terminal ileum diverticulitis

39F with LLQ pain

What do you see ?

Left UVJ stone

80

Left UVJ stone

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59M, left flank pain & hematuria

Ruptured AAA

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21F with painful voiding

Ketamine-induced cystitis

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69M, diffuse low abdominal pain

Difficult voiding and defecation for two weeks

Colovesicular fistula
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95M, abdominal pain with bloody ascites

Bladder rupture

85

Soft tissue & MSK echo

86

MSK
1. 2. 3. 4. 5.

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Outlines
US anatomic considerations Skin and soft tissue infection Long Bony fracture evaluation


Skin Subcutaneous tissue Fascial planes Muscles Tendon
Echogenic Hypoechoic Traverse by irregular strands of hyperechoic connective tissue Hyperechoic; regular thickness Striated appearance on long axis scan Fibrillar; echogenic Anechoic (Artery versus Vein) Irregular, circular, echogenic; with hypoechoic rim Echogenic cortices and dense acoustic shadows

Vascular structures Lymph nodes Bones


(5-10MHz) (depth)(focus) (longitudinal & transverse) & (Split screen)
Stand-off pad Water/gel-filled glove Water bath technique

Water/gel-filled glove

EUS &

 &
Cellulitis Subcutaneous abscess
Cobblestone-like appearance Variable appearance Most: hypoechoic; spherical mass Content:
Hyperechoic sediment Septae Gas Isoechoic or hyperechoic Liquefied pus
induced motion of the content

Necrotizing fasciitis

Marked thickened of SC layer A layer of anechoic fluid, Subcuatneous gas

greater than 4 mm adjacent to deep fascia Acoustic shadow Reverberation artifact

Cellulitis
Nonspecific Indicative of edema Skin Subcutaneous tissue Compare to unaffected side

Normal v.s. Cellulitis

EUS improves accuracy of superficial abscess detection

Squire BT, et al. AEM. 2005;12:601-606

NTUH experience
diffuse thickening of the SC tissue a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer 66 patients (17,NF) Sensitivity: 88.2% Specificity: 93.3% PPV: 83.3% NPV: 95.4% Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451

EUS for DVT survey

Primary component
Visualize the venous structures Detect gray-scale compressibility Lack of compressibility DVT

Secondary component
Use of Doppler to evaluate for abnormal flow

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

Position for femoral area

Femoral vessels

72F with fever and left leg pain

102

FASTER

Rib

Rib fracture

Rib fracture

Normal sternum

Sternal body fracture

Femur

Femoral shaft fracture

Tibial shaft fracture

50M with abdominal pain

What do you see ?

Urachal cyst abscess

113

42F, low abdominal pain

What do you see ?

Abdominal wall hematoma

114

54F with fever and painful back mass

What do you see ?

Back carbuncle
115

58M s/p thyroidectomy

Neck abscess
116

56M with left thigh pain

What do you see ?

Lymphadenopathy
117

75M with anal pain and fever

What do you see ?

Perianal abscess
118

50M,

Identify toe FB

119

19M

Shoulder dislocation and reduction

120

78F with fever and right hip pain

Septic arthritis
121

Take Home Message

Know anatomy

Find landmark

Recognize patterns


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