VOTW: Lost my Appy-tite

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This week's VOTW is brought to you by Drs. Mark Calandra, Evan Mahl, and the Ultrasound Team (Drs. Jessie Chen and Lawrence Haines)!

HPI: 20 yo male with RLQ pain since last night with no associated symptoms.

Appendix POCUS anatomy review

You can usually find the appendix draping over the iliac vessels



Video/Image 1: Non-compressible structure, with “target sign”, >6 mm



Video/Image 2: Dilated, tubular structure with likely appendicolith


POCUS appendicitis criteria:

  1. Noncompressible tubular structure

  2. >6 mm

  3. Other signs: “ring of fire” (w/color flow), edema in the area

Case conclusion: General surgery consulted and patient went to OR for surgery for acute appendicitis!

References:

  1. https://www.thepocusatlas.com/new-blog/appendicitis

  2. https://coreultrasound.com/appendicitis/

VOTW: "Eye-Yahh!"

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This week’s VOTW is thanks to Drs. Jennie Xu and Leily Naraghi!

HPI: 56 yo male with PMH of HTN presenting for sudden near complete vision loss in his right eye since 1pm yesterday.

Review of POCUS eye anatomy



Image/Video 1: Retinal detachment - you can differentiate this from vitreous hemorrhage because retinal detachments are typically thicker and are tethered to the optic nerve posteriorly.

Image/Video 2: “Washing machine sign” is concerning for vitreous hemorrhage

There are ways to figure out if a retinal detachment is “mac-on” or “mac-off”. The macula is temporal to the optic nerve in each eye. “Mac-on” retinal detachments are true ophthalmological emergencies and need to go to the OR emergently to have the retinal reattached and save their vision. It's hard to be sure though so if you see a retinal detachment, consult ophthalmology.

Conclusion: Patient was transferred to SUNY Downstate for ophthalmological repair of partial retinal detachment.

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