VOTW: Uterus Didelphys

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Case: 29 yoF G1P0 presented to the ED with vaginal bleeding and abdominal pain. A transabdominal ultrasound was performed that did not show a definitive IUP. Beta-HCG was elevated at ~30,000. The providers then performed a TVUS that showed a gestational sac without a clear yolk sac and a concerning second structure (video 1). OBGYN was consulted to rule out ectopic pregnancy and their repeat US showed an IUP. However, they also identified 2 uteruses and a vaginal septum, leading them to believe that the patient had uterus didelphys.

Video 1: Superficially you see a collapsed bladder. On the right side of the video, you see 1 uterine horn with a thickened endometrium and no gestational sac. On the left side of the video, towards the end of the clip, you can see an endometrium with a gestational sac. 

 

Uterus didelphys is a rare condition where a person develops 2 uteruses. It occurs when the Mullerian ducts do not fuse during embryologic development, resulting in 2 separate uteruses, each with its own fallopian tube and ovary (image 1). Some people also have 2 cervixes and 2 vaginal canals. This condition occurs in 0.3% of the population. Pregnancies in women who have uterus didelphys are considered high risk as there is less room for fetus to develop.

Case conclusion: the patient was counseled about risks and the need for close follow-up. She has a repeat ultrasound and appointment in the outpatient clinic this week.

Happy Scanning!

- Ariella Cohen, MD

References: https://my.clevelandclinic.org/health/diseases/23301-uterus-didelphys

VOTW: Do you know the muffin man?

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Case: 57 yoF with PMHx of osteoarthritis presented to the ED with right knee pain. A bedside US was performed that showed bulging of the right medial meniscus with surrounding edema Image 1, videos 1&2), consistent with a tear in the medial meniscus.

Meniscal Tear

How to assess the meniscus:

  1. Have the patient flex their knee slightly to 20-30 degrees (you can prop their knee up with a rolled towel) 

  2. Use the linear probe and place it longitudinally along the medial aspect of the knee 

  3. Identify the medial collateral ligament (MCL), which will appear as a hyperechoic and fibrillar structure, extending from the medial femoral condyle to the proximal tibia

  4. The meniscus will appear as a triangular structure that sits between the femur and tibia, under the MCL

5. A meniscal tear is identified with a well-defined anechoic or hypoechoic area surrounding the meniscus. It can cause extrusion of the meniscus as a result of surrounding edema, described as a "muffin top". There may also be increased vascularity in the surrounding area when color flow doppler is applied

Note: The same process can be repeated on the lateral aspect of the knee to assess the lateral meniscus (image 3).

Case conclusion: While the patient had pain with flexion, she was able to ambulate independently. She was discharged with orthopedic follow-up and conservative measures.

Happy scanning! 

Ariella Cohen


References: 

https://theultrasoundsite.co.uk/ultrasound-case-studies/

https://ultrasoundpaedia.com/knee-normal/

https://www.nysora.com/ultrasound-of-the-musculoskeletal-system/chapter14-knee-preview/

Poo-and-fro

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94 yoF with PMHx of gastric cancer and recent SBO (managed non-operatively) presented to the ED with worsening abdominal pain, constipation, and obstipation.

An ultrasound was performed that showed multiple signs consistent with an SBO:

 

  • Image 1: Dilated loops of bowel > 2.5 cm.

  • Video 1: To-and-for movement of fluid in the bowel. Normally, feculent material should only move in the direction of peristalsis. However, if there is a distal obstruction, you will see feces move back and forth as it attempts to move past it.

  • Video 1: Keyboard sign - when the plicae circulares, finger-like projections of the jejunal inner wall, become more prominent during an obstruction.

SBO

Other sonographic signs of SBO include:

  • A thickened bowel wall > 3 mm.

  • Free fluid between the loops of bowel. 

  • Decreased/absent peristalsis. (Note: Free fluid between bowel loops and lack of peristalsis may indicate bowel ischemia and a worse prognosis.) 

Case conclusion: CT scan was done that showed a distal small bowel obstruction. The patient was admitted to SICU for serial abdominal exams and non-operative management of her SBO.

Happy scanning!

- Ariella Cohen, M.D.

 

References

  1. https://www.emdocs.net/us-probe-ultrasound-for-small-bowel-obstruction/#:~:text=%E2%97%8B%20Jejunum%20will%20have%20%E2%80%9Cvalvulae,known%20as%20the%20keyboard%20sign).&text=%E2%97%8B%20Ileum%20will%20not%20have%20haustra%20or%20valvulae%20conniventes.&text=Look%20for%20compressibility.

  2. https://coreultrasound.com/small-bowel-obstruction/

  3. https://www.emhum.com/?p=472

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