The patient initially received a venous doppler ultrasound that showed no evidence of a right or left femoropopliteal venous thrombus. Due to the high suspicion of a DVT given the symmetric swelling to the entire limb and acute onset of pain, a CTV was ordered. The transverse view of the CTV showed chronic thrombotic occlusion of the proximal left common iliac vein associated with compression from the right common iliac artery (figure 1, transverse image of CTA), as well as thrombotic occlusion of the left internal iliac vein tributary and corresponding left ascending lumbar vein. Given the previously mentioned clinical context, these features suggested the diagnosis of May-Thurner syndrome.
Point of care ultrasound (POCUS) revealed hyperechoic material in the vitreous consistent with a vitreous hemorrhage. On the ultrasound images, there is visible hyperechoic debris seen floating in the vitreous as the patient moves his eye. Since the vitreous is typically anechoic (black) in color on ultrasound, turning up the gain on the ultrasound machine makes these findings easier to see and often highlights abnormalities, such as this hemorrhage (see annotated still).
A transabdominal point-of-care ultrasound (POCUS) was initiated to determine whether an abnormality to the pregnancy could be identified. Curvilinear probe was used. Our transabdominal POCUS, in the transverse plane, showed a heterogenous mass with multiple anechoic areas in the uterus. The white arrow on the ultrasound identifies these findings. The classic “snowstorm” appearance was concerning for molar pregnancy.
A CT scan of the abdomen and pelvis with intravenous contrast for evaluation of new onset abdominal pain and distension was obtained in the emergency department. The axial view (CT Image A) shows the coil pack from the prior coil-assisted retrograde transvenous obliteration procedure, seen in the left renal vein and gastric varix (red arrow). The path of the coil (yellow arrow) is continuous into the inferior vena cava (CT Image B). It is then seen (CT Image C) situated in the right ventricle (green arrow). Finally, the coil pack is seen in a coronal section, demonstrating its upward path (blue arrow) in the inferior vena cava. (CT Image D). Additional findings included ascites with advanced cirrhosis. As noted in the CT images, a vascular embolization coil was seen within a varix near the junction of the left renal vein. This appeared to have unraveled and extended superiorly into the inferior vena cava and ultimately into the right atrium and right ventricle.
A focused assessment with sonography in trauma (FAST) exam was performed initially to evaluate for intra-abdominal injury given the clinical picture. A phased-array ultrasound transducer was placed in sagittal orientation along the patient’s right and left flank, demonstrating extensive heterogenous fluid collections in Morrison’s pouch (red arrow), subphrenic space (solid green arrow), and splenorenal recess (dashed green arrow). To further evaluate, a phased-array transducer was placed over her pelvic area in transverse orientation, demonstrating, a large, heterogeneous mass (outlined in yellow arrows). The surgical team was promptly consulted and blood products were ordered. Although there was concern for impending hemorrhagic shock due to patient’s presenting tachycardia, the patient was hemodynamically stable enough for a CT scan of her chest, abdomen, and pelvis. The CT scan showed large-volume ascites, which exerted mass effect on all abdominal organs with centralization of bowel loops. Additionally, there was a large, 6.4 x 6.8 x 10.9-centimeter, midline pelvic mass (outlined in blue arrows).
A point-of-care ultrasound of the urinary tract was performed, evaluating the kidneys and bladder. When imaging her kidneys, right-sided hydronephrosis was noted with a normal appearance to the left kidney. To further evaluate, a curvilinear probe was placed on her bladder with color doppler to assess for ureteral jets. Ureteral jets are seen as a flurry of color ejecting from each of the ureters as urine is released from the ureterovesical junction. In a healthy patient, this finding should be seen ejecting from both ureters every 1-3 minutes as the kidneys continue to filter the blood and create urine to be stored in the bladder. In our patient, however, ureteral jets were only noted on the left side (arrow), which was significant in further verifying our suspicion of right ureteral obstruction.
The ultrasound images reveal hepatomegaly and an increased echogenicity of the liver parenchyma that is diffuse. The increased echogenicity can be best appreciated by a comparison to surrounding structures. It is important to note that the increased echogenicity is non-focal and consistent throughout the entire liver in multiple views. These findings can be consistent with nonalcoholic steatohepatitis as well as glycogenic hepatopathy.
An ultrasound (US) of the abdomen was obtained to evaluate for possible pyloric stenosis (see US transverse/dopper imaging). While imaging showed a normal pyloric channel, it revealed an unexpected finding: a complex cystic mass arising from the right adrenal gland (yellow outline), measuring 5.8 by 4.0 by 6.4 cm with calcifications peripherally and mass effect on the kidney without evidence of vascular flow (blue arrow). Computed tomography (CT) of the abdomen/pelvis with IV contrast was subsequently obtained and measured the lesion as 2.8 by 4.6 by 4 cm without evidence of additional masses, lymphadenopathy or left adrenal gland abnormality (see CT axial, coronal, and sagittal imaging).
Facial ultrasound revealed local inflammatory changes such as increased echogenicity and heterogeneity in the soft tissues of the right cheek, suggestive of soft tissue edema. There was evidence of a prominent right parotid gland with increased heterogeneity suggestive of a traumatic injury. Additionally, facial ultrasound demonstrated a 6mm ill-defined anechoic collection within the right cheek without increased doppler flow (green arrow), thought to represent a focal area of edema instead of an abscess.
Point of Care Ultrasound as a Diagnostic Tool to Detect Small Bowel Obstruction in the Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J8XD1G
The ultrasound findings suggestive of small bowel obstruction (SBO) are typically visualized in video; however, certain still images can also demonstrate SBO including greater than three dilated loops of small bowel (>2.5 cm), thickened-walled bowel (>3 mm), visualization of plicae circulares, and extraluminal fluid caused by inflammatory changes along the bowel wall, which are all highly suggestive of SBO.3 In this patient’s case, we were able to visualize several dilated loops of small bowel (red arrow) with oscillating intraluminal contents known as “Whirl Sign.” Additionally, we were able to visualize extraluminal fluid, demonstrated as an anechoic triangular-shaped collection. The characteristic shape of this triangular shaped collection of fluid is known as a “Tanga Sign,” given its name due to way it looks similar to the lower half of a bikini (blue arrow). Tanga sign can occur when the loops of dilated bowel appear prominent in contrast to the inflammatory extraluminal fluid in an SBO. These ultrasound findings were highly concerning for SBO which was later confirmed on CT imaging of the abdomen, which demonstrated SBO with a transition point in the left lower quadrant.