Great case of the week from Yale EM Ultrasound. This is a great POCUS education site.
Yale case of the week! 77yo s/p surgery with abdominal pain and distension – not subtle but quick diagnosis… #POCUS @yaleem2 pic.twitter.com/pi2tatxK7E
— Yale EM Ultrasound (@Yale_EUS) January 10, 2017
Hyperactive, dilated small bowel loops with free intraperitoneal fluid. (c.f. paralytic ileus where bowel loops are dilated but static)
Ultrasound can be used to assess the main vascular structures in the abdomen. The most common examination is to look for an Abdominal Aortic Aneurysm (AAA).
To find your aorta, start by placing the probe on the patients’ abdomen in transverse, just below the xiphoid process. You will see anechoic oval and circle, above a crescent shadow. These represent the IVC, Ao and Vertebra, respectively. Using firm pressure, slide probe downwards toward the umbilicus, at which you should see the Ao bifurcate into the Iliac arteries. Once found in transverse, try this motion while the probe is in the sagittal plane.
An aortic aneurysm is a focal dilation of the Aorta, and should be greater than 3.0 cm when measured from anterior to posterior.
The IVC is located just right of midline, and can be seen by the liver. It is best appreciated in the sagittal plane. Notice how the IVC is phasic, changing size with respiration. If you ask your patient to breathe in, or “sniff”, you should see the vessel collapse more than 50%, demonstrating a normal venous pressure.
![C60_Liver_IVC_Midline[3]_1](https://i0.wp.com/www.figbus.net/wp-content/uploads/2017/02/C60_Liver_IVC_Midline3_1.jpg?resize=326%2C217)
Images:
http://reference.medscape.com/features/slideshow/ultrasound
http://www.sonosite.cn/clinical-media
Cholecystitis is one of the more common ailments seen in emergency departments, and one of the most frequent indications for an abdominal ultrasound. Gallstones will appear as echogenic, or bright white, round stones within the gallbladder, with shadows posterior. The gallbladder itself will appear anechoic, or black, tubular structure, adjacent to the right lobe of the liver and the main portal vein. When assessing for cholecystitis here are some other sonographic signs:
-Look for mobility. Do the stones roll when you move the patient? Look at the gallbladder supine, stone will be sitting towards the “neck” of the gallbladder, because that is dependent location. Now try tolling your patient LLD, or even sitting up. The stones should roll to the fundus! If not, are they stuck in the neck?
– Is the gallbladder wall thick? Measure the wall in transverse and it should be less than 3 mm
-Is there free fluid? Look for a pointy, “triangle” shaped anechoic area beside the GB.
– Is there a positive Murphy’s Sign? When you apply pressure to the gallbladder, does this correspond with the patient’s area of pain? Often the response is quite clear.
Images courtesy of Radiopedia.org:
Case courtesy of Dr Derek Smith, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/42795″>rID: 42795</a>
Case courtesy of Dr Andrew Dixon, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/9558″>rID: 9558</a>
Case courtesy of RMH Core Conditions, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/38022″>rID: 38022</a>
Case courtesy of Dr M Osama Yonso, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/16769″>rID: 16769</a>
It’s Thanksgiving weekend, and what a fitting time to talk about the gallbladder. With the rich meals associated with the holidays, it’s no surprise that the emergency department fills with patients who have biliary tract disorders such as gallstones and cholecystitis.
Here are some tips on how to find the gallbladder on ultrasound. Begin with the patient supine, placing probe sagittally and to the right of mid-line. The image should show liver and the gallbladder. Often a held inspiration can help move obscuring bowel gas. Now often patients do not have a nice supine window, so next view to try is intercostal. Place the probe at right lateral position, scanning between the ribs. Next look at the gallbladder when the patient is in a left lateral decubitus position. Often this is the best view to look at the GB because the liver creates an acoustic window and the bowel moves to the left. Again, place probe subcostally, right of mid-line, and sweep with your probe in the sagittal position.
Below is an ultrasound image of a normal gallbladder. Stay tuned for further posts about gallbladder pathology!
Case courtesy of Dr Henry Knipe, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/48019″>rID: 48019</a>