Ultrasound Case of the Week 01/27/2014

Ultrasound Case of the Week

01/27/2014

56 year old male with history of HTN, GERD and alcohol abuse and 5 day s/p bilateral L4 laminectomy presented to ED with nausea and vomiting for past five days. Patient had poor appetite, limited PO intake since the procedure and endorsed 2 episodes of non-bloody bilious vomiting accompanied by abdominal soreness. Had no bowel movements for past four days. He was taking Norco for past 3-4 months for back pain and had recently taken it about q6 hours at home since his surgery. Denied any hematemesis, melena and hematochezia. Had history of large bowel resection 4 years ago for a colonovesicular fistula and was immunosuppressed (on enbrel).

Vital signs: 96.4°F/ P 80 / RR 18 / 98% sat

Exam: Patient was in NAD, A & O x3; heart, lung, head and neck, and extremity exam unremarkable. Abdomen was mildly obese and distended with hypoactive bowel sounds, nontender with no rebound pain or guarding. Three healed scares appreciated.

Labs: Lactate 1.2; Na 123; anion gap 17; BUN 91; Cr 4.83; U/A neg; lipase 48

Xray abdomen: Dilated small bowel loops with multiple air-fluid levels most likely due to partial distal small bowel obstruction.

IMAGES:

Wrap Up:

56yo M presented with SBO like symptoms, most likely due to post op ileus due to Norco use vs adhesions. Nausea and vomiting improved with NG placement, IVF and NPO status. Surgery performed a LOA during ex-lap, which resolved the SBO.

Review/Discussion:

SBO can be due to a mechanical cause or due to a pseudobstruction (aka ileus).

Possible causes of mechanical obstructions include adhesions, hernias, tumors, Crohns disease, intussuception, volvulus, or gallstone ileus. Possible causes of ileus include narcotics, viral infections, mesenteric ischemia, surgery, and longstanding diabetes.

The general treatment of an SBO following imaging is: IVF, NPO, NG tube, enema, surgery if need be.

U/S findings of an SBO: Dilated bowel >25mm, increased intraluminal fluid, alternating peristalsis, Keyboard sign (due to plicae circulares)

X ray findings of an SBO: air fluid levels, dilated loops of bowel

Finding of a recent study: EP-performed ultrasound compares favorably to x-ray in the diagnosis of SBO. (1)

Sources and More Resources:

(1) http://www.ncbi.nlm.nih.gov/pubmed/20732861 http://www.youtube.com/watch?feature=player_detailpage&v=MoZx-EV3Aso

http://sonospot.wordpress.com/2013/03/06/sonostudy-emergency-docs-detect-small-bowel-obstruction-by-us-as-good-as-radiologists-foamed/

http://www.ultrasoundpodcast.com/2012/10/episode-36-small-bowel-obstruction/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3299163/

01/21/2014 Case of the Week

US Saves the Day (Yet Again)

39 yo male with PMH significant for GERD presents to the ER c/o of RLQ pain for 1 week. He was given “pain medicine” by his doctor after 5 days of pain with no improvement so he came to the ER. The pain is sharp and does not radiate. The pain is an 8/10 at peak and is relieved by rest and aggravated with movement. He reports no nausea, vomiting, fever or chills. He reports having a similar episode of pain 1 year ago that resolved promptly with a PPI. His last meal was yesterday and he reports having an appetite despite the pain. He is passing gas and had a BM this morning.

Review of systems was negative except for what was noted in HPI

Vital signs: Stable, w/o fever

Respiratory Rate: 18, HR 75,  99% SPO2 on RA, BP 155/97, 37deg C, 98.6 deg F
Examination: unremarkable except for mild tenderness to deep palpation of RLQ 
General appearance: 39 yo obese male in no acute distress.Skin: Warm. Dry. No rash.Scalp: Within normal limits.
Neck: No tenderness.
Eye: Pupils equal, round, and reactive to light. Extraocular movements intact. Normal conjuctiva. Ears, nose, mouth and throat: Oral mucosa moist. No pharyngeal erythema or exudate.
Heart: Regular rate and rhythm, no murmurs.
Respiratory: Lungs clear to auscultation bilaterally. Respirations nonlabored.
Abdominal: Soft. Non distended. Normal bowel sounds. Mild RLQ tenderness with deeppalpation (patient obese). No rebound or guarding. No CVA tenderness.
Genital: No tenderness, no discharge, normal external genitalia.
Back: Nontender. Normal range of motion. Normal alignment.

Laboratory results did not reveal any significant abnormalities: CBC and CMP wnl. There was no white count (8.9). 

NA: 138 mmol/l, K: 3.7 mmol/l, CL: 101 mmol/l, CO2:   26 mmol/l,  AGAP: 11 mmol/l, CA: 9.3 mg/dl, BUN: 7 mg/dl
CRE: 0.84 mg/dl, GLUC: 89 mg/dl, TBIL: 0.8 mg/dl, DBIL: 0.1 mg/dl, ALP: 92 u/l, AST: 19 u/l, ALT: 25 u/l, ALB: 4.3 g/dl, WBC: 8.9 thous/ul,  RBC: 5.30 million/ul, HGB: 16.1 g/dl, HCT: 46.5 %,  PLT: 344 thous/ul


 

  

Patient with low suspicion for appendicitis given lack of white count, afebrile, unremarkable exam, discharge pending a “quick look” ultrasound:

 abdomen/pelvis w/wo contrast: 
The appendix is identified and appears diffusely mildly thickened (1 cm) and indistinct. There is
localized stranding of the fat adjacent to the pancreas, without fluid collection or free air. No
dilated bowel loops are demonstrated

 IMPRESSION:

1. CT findings of acute appendicitis without evidence of abscess or bowel obstruction.

Surgery as consulted and patient scheduled for surgery following am***
Review/Discussion

Acute appendicitis is the most common abdominal surgical emergency
A meta-analysis by Terasawa et al. in 2004 described US as having a sensitivity of 86% and specificity of 81% in detecting acute appendicitis
To help visualize the appendix: Crossed leg maneuver
Have the patient cross the right leg over the left as far as possible without rolling the hip off the table and apply firm pressure to the transducer to compress air-filled loops of bowel
Normal findings A normal
appendix in cross- section (seen less than 15% of the time)

In long axis, appendix would demonstrate compressibility during real time imaging.

Appendicitis on USDiagnosis is made by recognition of a tubular structure greater than 6mm in the RLQ that is non- compressible and lacks peristalsis