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Basics of abdominal Ultrasonography

Dr . Ahmed El Zeneini. Msc Radidiagnosis Specialist Nasser Institute Hospital


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Definition

Ultrasonography is study of internal organs or blood vessel using high frequency sound waves, the actual test called ultrasound scan or sonogram.

Definition

Ultrasound are sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz.
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Basic Ultrasound Physics: Sound is a series of pressure waves(mechanical waves) propagating through a medium. One cycle of the acoustic wave is composed of a complete positive and negative pressure change. The wavelength is the distance traveled during one cycle, the frequency of the wave is measured in cycles per second or Hertz (Cycles/s, Hz).

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Principle * A sound waves travels in a pulse & when it is reflected back it becomes an echo. The pulse-echo principle is used for ultrasound imaging. * A pulse generated by one or more piezoelectric crystals in an ultrasound probe or transducer. * Ultrasound probe crystal is shocked by single extremely short pulse of electricity to vibrate at a frequency determined by its thickness.
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sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,
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Ultrasonography
Advantages - No ionizing radiation - Safe in pregnancy - No known side effect - Cheap, portable machine - Minimum preparation of patient . - Painless, noninvasive - Direct vision for biopsy Disadvantages * Sonographer should be expert in diagnosis . * Performing & interpreting the examination can be extremely difficult.

Ultrasonography Machine

Introduction

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1. Ultrasound waves
They are waves of very high frequency ranging between 3.5 10 MHz and up to 20 MHz in endosonography. When the frequency the resolution and penetration .
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In adults the frequency used =3.5 MHz. In children the frequency used=5 MHz.

In small parts =

MHz.

In endosonography= 7.5-20 MHz.


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2. Echo pattern

It means the reflection of waves , and this depends on the material which is penetrated by US.
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2. Echo pattern Echofree : When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement .
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Posterior enhancement & mirrored side

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2. Echo pattern Echogenic : When ultrasound waves pass through solids (bones stone) all waves are reflected and appears as white color with posterior shadow .
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Posterior shadow

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3. Transducers
a. Shape
Linear Sector Linear convex

b. Frequency
Single Dual Range

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Anatomical overview of upper abdomen

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Liver

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Liver 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles .
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Liver

Size: Lt. Lobe span Rt. Lobe span (5-10 cm). (8-15 cm).

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Liver 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles .
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Liver

Focal lesions

1. Single or Multiple. 2. Size 3. Site (segmental anatomy)

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Liver (focal lesion) 4 .Echopattern a. Echofree e.g. hepatic simple cyst, hydatid
cyst.

b. Hypoechoic e.g. amoebic liver abscess,


lymphoma. c. Hyperechoic (echogenic) e.g.haemangioma . d. Heterogeneous e.g. cancer, secondary metastasis.

5.Differential diagnosis
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Hemangioma of liver (hepatic hemangioma):

Images show a large (8 cms.) rounded, well defined, hyperechoic, noncalcific mass in the right lobe of liver. There is a moderate amount of acoustic enhancement posterior to the lesion.
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Multiple metastases in the liver

Heterogeneous echogenicity
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Liver metastases
Heterogeneous echogenicity

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Hydatid cyst or echinococcosis of liver

Echo-free

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Amebic liver abscess


hypoechoic nature of the lesions suggesting further breakdown of the solid liver tissue ( liquifactive necrosis)

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Liver 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles.
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Liver

Diffuse liver disease

Schistosomal hepatic fibrosis: (Thickened portal tracts):


Portal tracts appear in US as portal vein radicles . If the wall of these radicles are thickened, we measure the portal tracts (outer-outer diameter). If the diameter is more than 3 mm in more than 3 tracts p Periportal Thickening.
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Liver

Pp thickening

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Liver
Pp thickening

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Liver

Diffuse liver disease


Liver cirrhosis: coarse echopattern with: (Miliary =echogenic fine liver dots). * Irregular surface.
* Large caudate lobe *Attenuated hepatic veins.
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Liver

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Liver

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Liver

Diffuse liver disease


Bright liver: Increase brightness less dark. Normally, the echopattern of the liver is slightly brighter than the renal parenchyma.

D.D of Bright liver .


Fatty liver (DM Hyperlipidemia-obese patients) Chronic hepatitis Liver cirrhosis
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Liver Bright liver

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Liver
Bright liver

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Liver 1.Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles.
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Liver

Hepatic Vasculature

A- Portal Vein: - The diameter is normally up to 12mm, in fasting adults. - From 13-17mm in suspected cases of portal hypertension.
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Liver

Hepatic Vasculature

->17 it is sure portal hypertension. NB: - In some cases of portal hypertension the P.V diameter is within normal due to the presence of collaterals.
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Liver

Portal Vein Thrombosis


Occurs in association with: H.C.C. After sclerotherapy. After splenectomy
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Liver
Portal Vein Thrombosis

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Liver
Portal Vein Thrombosis

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Liver

Collaterals

The presence of any collaterals is a sure sign of Portal Hypertension 1- Para umbilical vein : seen in the falciform ligament. 2- Coronary vein : seen in the inferior surface of the left lobe. Normally less than 5 mm. It is related to oesophageal varices.
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Liver

Collaterals

3- Splenic hilum collaterals:  lieno-renal collaterals (benign) around splenic vein& directed to the kidney  lienogastric : Directed to stomach. related to fundal varices..
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Liver

Splenic hilum collaterals

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Liver

Coronary vein

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Liver

Hepatic Veins Importance of hepatic veins:


* Attenuated in Liver cirrhosis and venoocclusive disease. * Dilated in congested hepatomegaly. * In segmented Anatomy.
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Liver

Dilated HVs.

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Liver

Attenuated HVs

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Liver

Normal HVs.

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Liver

Attenuated HVs

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Liver

Attenuated HVs

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Liver 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5.Intrahepatic biliary radicles .
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Liver

Intra-hepatic Biliary Radicles

* Normally they are not seen, when dilated as in Obstructive Jaundice pdouble barrel sign (portal vein tributary and intrahepatic bile radicle ).
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Intra-hepatic Biliary Radicles *When the obstruction is intra-hepatic (e.g hilar cholangio-carcinoma) there is no dilatation of CBD. * when the obstruction is extra hepatic there is dilatation of CBD. more than 8 mm
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Liver

double barrel sign

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Liver

double barrel sign

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Liver

Causes of bile duct obstruction


* Stones in the CBD, hepatic duct, or ampulla of vater * Cancer head of pancreas, ampulla of vater, cholangiocarcinoma. * Lesions in the porta hepatis as porta hepatis lymph node enlargement. * Fasciola or ascaris.
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Gall Bladder

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Normal Anatomy of Gall bladder

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Gall Bladder

Size Wall thickness. Contents


Stone. Parasites. Mud.

Masses polyp cancer


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Gall Bladder

Size
Long axis 6-12 cm , short axis 3-5 cm
- Contracted < 5 cm. - Distended > 12 cm when the patient is fasting.
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Gall Bladder

- Size - Wall thickness. - Contents


Stone. Parasites. Mud.

- Masses polyp cancer


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Gall Bladder

Wall thickness

- Measured in the side in contact with the liver. - Normally it is up to 3 mm. - From 3-5 mm >>> suspect thick wall.
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Liver

Wall thickness

* > 5 mm It is a thick wall gall bladder which is seen in:


Cholecystitis (acute-chronic). Ascites . Hepatitis ( viral). Schistosomiasis .
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Gall Bladder

Size Wall thickness. Contents


Stone. Parasites. Mud. Masses polyp cancer
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Gall Bladder

Contents
* Stones:
seen inside the gall bladder in all positions, mobile except at the neck. they appear white with posterior shadow.

* Mud (infected bile) * Thick bile.


Change with changing position with or without presence of stones. The picture occurs in the presence of thick bile in patients on IV fluids for 3-4 days with inflamed GB.
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Gall Bladder

Contents

Parasite:
Fasciola appears pearl shape. Move as a whole. Ascaris rare appears as thrill inside G B.

Cancer & polyps:


Polypoidal or heterogeneous mass.
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Gall Bladder

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Gall Bladder

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Gall Bladder

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Gall Bladder

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Gall Bladder

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Gall Bladder

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Mirizzi syndrome
This syndrome is caused by impacted calculus in the Gall bladder neck or cystic duct causing extrinsic compression of the common hepatic duct. A common predisposing factor for this is the low insertion of the cystic duct into the common hepatic duct. This makes the cystic duct almost parallel to the common hepatic duct.
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Hartmann's pouch calculus:

is an out-pouching of the wall of the gallbladder at the junction of the neck of the gallbladder and the cystic duct.
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Spleen

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Spleen

Size
Measure the diagonal axis: Normally it covers the upper 1/3 of the left kidney. - Longest axis (diagnostic) - Relation to kidney. - Relation to costal margin.
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< 12 cm.

Spleen Focal Lesions

* Causes:
Lymphoma. Cyst (simple-hydatid ). Infarction of a part (triangular area & base toward the edge). Sarcoma.
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Spleen Diffuse disease

Hemosidrosis: White dots in spleen Means Portal Hypertension

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Spleen

Longest axis

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Spleen

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Spleen

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Normal kidney

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Anatomy
Kidneys are retroperitoneal, T12 - L4 Right kidney is lower than the left kidney Right kidney is posterio-inferior to liver & gallbladder Left kidney is inferior-medial to the spleen Adrenal glands are superior, anterior, medial to each kidney

Hepatic Veins

Spleen
Celiac axis

Liver
SMA Right kidney Renal artery Renal vein Left kidney

Anatomy
9-12 cm long, 4-5 cm wide, 3-4 cm thick Gerotas fascia encloses kidney, capsule, perinephric fat Sinus
Hilum: vessels, nerves, lymphatics, ureter Pelvis: major and minor calyces

Parenchyma surrounds the sinus


Cortex: site of urine formation, contains nephrons Medulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids

Medullary pyramids Minor Calyx

Kidney Anatomy

Major Calyx

Sinus

Medulla Renal capsule Cortex

Sonographic Appearance
Ureters are normally not seen Renal pelvis is black when seen through urine Renal sinus is echogenic due to fat Medullary pyramids are hypoechoic Cortex is mid-gray, less echogenic than liver or spleen. Capsule is smooth and echogenic

Common Pitfalls in Renal Scanning


Failure to scan both kidneys Mistaking prominent renal pyramids for hydronephrosis Mistaking prominent pyramids for cysts Confusing normal renal arteries for the ureter

Right Kidney ( normal)

Left Kidney ( normal)

Rt. lobe

Spleen

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Longitudinal image of normal Rt. kidney

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Degree of Hydronephrosis

Normal

Mild

Moderate

Severe

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Fungating bladder mass

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Cortical cysts or simple renal cyst:

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Chronic renal failure (Medical renal disease):

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Kidney Stone:

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Sonography of very large renal calculi:

This huge calculus was discovered on ultrasound imaging of the left kidney. The calculus measuring almost 7 cms. is seen occupying the lower half of the left renal pelvis and the adjacent calyces. There is also mild dilatation of the renal pelvis due to urinary tract obstruction
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Multiple renal calculi:

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Normal pancreas.

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Normal pancreas.
2- head 31- liver; of the pancreat pancreas ic body; 65- tail of superior 4the mesente Wirsung pancreas ric 's duct; ; artery; 7- IVC. 8Aorta; 9- spine.

10- GB
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Tumour of the pancreatic head

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Pancreatic cyst

an oval, echo-negative formation with well-defined, even outline visualised within the pancreatic body projection
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Pelvic ultrasound.

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Large urinary bladder calculus

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A case of Lower urinary tract obstruction

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Benign prostatic hyperplasia

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Measuring the uterine dimensions


1) cervix length; 2) body length; 3) antero posterior length on the level of the uterine body; 4) width; 5) endometrium thickness.
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Normal ovaries at the beginning of the cycle.

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Uterine fibromyoma .

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Normal uterine pregnancy. Duration of gestation: 4 weeks


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Pleural effusion:

large, clear, hypoechoic fluid collection in the left pleural space. The left lung has collapsed into a small mass of tissue compressed by the effusion. A small fibrotic band is seen traversing the fluid.
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Case study

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Case 1 A 38-year-old man comes to the emergency department after falling 15 feet off scaffolding at work. His systolic BP is 90; his heart rate is 125 bpm. He is on a backboard and in a C-spine collar and complains of severe pain in his back and abdomen. You perform the FAST ultrasound scan as part of your trauma evaluation and find the following rabiezahran@Gawab.com

Image case 1 Your diagnosis: Significant amount of intra-abdominal free fluid. Shown here is the peri-hepatic area, also called Morrisons pouch. ED management: Immediate transfer to the operating room for exploratory laparotomy. The patient is clinically unstable and has a presumed intra-abdominal bleed, most likely from a solid organ injury or vascular injury.
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Case 2 A 42-year-old female patient complains of sudden severe right flank pain. During your interview she is restless and seems unable to find a position of comfort. On exam she is afebrile, her vital signs are stable and she has tenderness over her right flank. You perform a bedside ultrasound and find the following:
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Your diagnosis: Mild hydronephrosis right. ED management: On extended bedside ultrasound her left kidney appears normal, also her aorta and FAST exam show no abnormalities. Symptomatic treatment with IV fluids and pain control resolve all symptoms. Patient will need urgent outpatient follow-up with urology for renal colic with hydronephrosis without signs of infection and normal renal function.
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Case 3 A 23-year-old woman presents to the ED with nausea and vomiting for the past few days. Her last period was regular but very light and she cant remember the exact date. She does not take birth control or fertility drugs. Her abdominal exam is unremarkable, on pelvic exam the cervical os is closed. You perform a bedside pelvic rabiezahran@Gawab.com ultrasound:

Your diagnosis: Early intra-uterine pregnancy. (Image courtesy of W. Hosek, M.D.) ED management: Nausea and vomiting resolve with IV hydration and medication. The patient is discharged with outpatient follow-up with OB and started on pre-natal vitamins.
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Case 4 A 45-year-old patient presents with upper abdominal pain. Her symptoms began after eating a burger. On exam she is tender over the right upper abdomen. She mentions that she had two similar episodes recently, but they were less painful. You start symptomatic treatment, order blood work and perform a bedside ultrasound:
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Your diagnosis: Acute biliary colic with multiple gallstones. On ultrasound exam you find multiple gallstones but the gallbladder wall and common bile duct appear normal. ED management: Blood work shows no infection or elevation of liver or pancreatic enzymes. The patient improves with symptomatic management and her pain resolves. She is discharged from the ED after surgical consultation and planned outpatient follow-up.
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