Point-Of-Care Ultrasound Use for Detection of Multiple Metallic Foreign Body Ingestion in the Pediatric Emergency Department: A Case ReportDOI: https://doi.org/10.21980/J83D2D
Bedside POCUS was performed on the patient’s abdomen using the curvilinear probe. The left upper quadrant POCUS image demonstrates multiple hyperechoic spherical objects with shadowing and reverberation artifacts concerning multiple foreign body ingestions. Though the patient and mother initially denied knowledge of foreign body ingestion, on repeated questioning after POCUS findings, the patient admitted to his mother that he ate the spherical magnets he received for his birthday about one week ago. The patient swallowed these over the course of two days. The presence of multiple radiopaque foreign bodies was confirmed with an abdominal X-ray.
The bedside ocular ultrasound (B-scan) was significant for small, hyperechoic signal (white arrow) in the distal aspect of the optic nerve, concerning for embolus in the central retinal artery. Subsequent direct fundoscopic exam was significant for a pale macula with cherry red spot (black arrow), consistent with central retinal artery occlusion (CRAO).
Upon arrival at the trauma center, a FAST revealed a large, well-circumscribed abnormality (red outline) deep to the liver (blue outline and star) and gallbladder (green outline and star). The right kidney and hepatorenal space were not clearly visualized. The remainder of the FAST showed no free fluid in the splenorenal space, pelvis, and no pericardial effusion. He had lung sliding bilaterally.
Bedside ultrasound was performed and showed thickened bowel wall (orange marker), fat enhancement (green marker), and phlegmonous structure with central echogenicity (yellow marker). Imaging of the abdomen and pelvis with CT showed marked wall thickening and inflammatory change involving a 7.0cm segment of the distal/terminal ileum suspicious for severe ileitis with phlegmon and microabscess on the coronal image (yellow arrow). Additonally, the transverse images show a small rim-enhancing focus within this region of inflammation measuring up to 1.4cm which could represent microabscess (yellow arrow). Diagnosis of diverticulitis by ultrasound is made by identifying the following findings: colon wall thicker than 5mm, fat enhancement, evidence of abscess, visualized diverticuli, air artifacts suggesting diverticuli, and tenderness with compression of the probe.6 Diagnosis of diverticulitis by CT is made by identifying the following findings: colonic wall thickening, pericolic fat stranding, abscess formation and enhancement of the colonic wall. Often, these signs are associated with an identifiable inflamed diverticulum.7
In transverse view, point-of-care ultrasound (POCUS) showed an anechoic circular true lumen (blue highlight) and half-circular anechoic false lumen (green highlight), separated by a near hyperechoic dissection flap (orange highlight) that pulsated with blood flow. When viewed in sagittal orientation, the anechoic true lumen (blue highlight) appears longitudinal, separated from the false lumen (green highlight) by a dissection flap (orange highlight). Stills showing the measurements of these dissections are also provided.
Point-of-care ultrasound (POCUS) demonstrates a large, subcutaneous mass with areas of mixed echogenicity. The mass contains fluid-filled, anechoic areas with internal septations and absent doppler flow. The majority of the mass appears isoechoic to the surrounding tissues with a hyperechoic border. Computed tomography (CT) of his right thigh shows a 16 x 8.1 x 9.5 cm heterogenous, complex mass within his hamstring muscles, inferior to the femur. His lab work was significant for a white blood cell (WBC) of 17.3 (103/µL).
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.