VOTW: You take my breath away!

HPI: 90 yo female presenting for worsening shortness of breath and tachycardia x 3 days and right leg pain x 2 weeks with difficulty ambulating.

POCUS showed:

ECHO A4C view (see video): note the size of the RV appears larger than the LV. This is a sign of right heart strain and in the appropriate setting (such as this one) can be concerning for a pulmonary embolism!

Compression views of the common femoral vein (CFV), femoral vein (FV), and popliteal vein (PV). See the echogenic material inside the popliteal vein which is suggestive of a DVT. Remember that during the acute phase of a DVT (<14 days), the clot may appear isoechoic to the blood inside the vein so you may not see this echogenic material and should rely more on your compression exam.

Review on how to do DVT US:

Linear probe

Patient in frog leg position

4 main areas to view

• Common femoral vein (CFV)-saphenous vein junction (SFV)

  • Clot noted in the SFV within 3 cm to the junction is treated as a DVT. More distally, if there is 5 cm worth of clot noted in the SFV it is also treated as a DVT.

• CFV branching into [superficial] femoral vein and deep femoral vein

• Mid/distal femoral vein

• Popliteal vein

  • Remember the popliteal vein is on top of the popliteal artery (pop on top!)

Tips:

• You often have to go much higher in the groin than you think to find the CFV-SFV junction

• Compression testing of the deep veins should not compress the artery (if it is, you’re pressing too hard and can miss subtle DVTs)

• Deep veins are paired with arteries so identify your landmarks to ensure you are looking at the correct vessels

• Use your non-scanning hand to help with compression of deeper veins by supporting the other side of the patient’s leg

Case conclusion: Patient with elevated troponin and BNP. CTA significant for bilateral PE’s. Labs and ECHO findings consistent with submassive PE. Patient started on heparin drip and admitted to the floor!

Happy scanning!

• The US Team

"Abscessed" with Bowel POCUS: Diverticulitis

HPI: 42 yo male with no PMH presenting for abdominal pain x 2 days. His physical exam was significant for LLQ tenderness with guarding and rebound.

POCUS showed (see video):

We initially thought the outpouching connected to the abscess was a diverticulum but on further review, it’s more likely to be a loop of bowel given its size.

What a diverticulum should look like:

CT scan for reference:

Diagnosing Diverticulitis on POCUS

• Use curvilinear vs linear probe

• Start at maximal point of pain > lawnmower technique

• #1: Find diverticula

• Looks like outpouching attached to loop of bowel

• Secondary findings:

• Bowel wall diameter >5 mm

• Prominent, fluid-filled bowel loops

• Pericolic fluid collections

• Increased pericolic fat (hyperechoic fat anterior to diverticula)

• Intraabdominal abscesses

Case conclusion: CTAP showed perforated diverticulitis with multiple intraabdominal abscess. Patient was taken for IR drainage with feculent/purulent drainage noted. Patient is still doing well on surgical service.

References

1. https://coreultrasound.com/diverticulitis/

2. https://www.ultrasoundgel.org/posts/SFPsfN9yJ-9uSp640QlWtg

3. https://www.ultrasoundcases.info/diverticulosis---diverticulitis-531/

VOTW: Small Bowel Obstruction

HPI: 60 yo male with PMH of cerebral palsy, hx of SBO s/p resection and PEG tube presented to ED for vomiting. 

POCUS showed:

Note the to and fro peristalsis. Usually bowel is not visualized this well on POCUS due to air artifact. This, in itself, is a sign of surrounding edema and fluid filled structures.

Note that this is small bowel because of the “keyboard” sign representing plicae circulares (vs haustra seen in large bowel)

SBO POCUS findings:

1. 3 dilated small bowel loops >2.5 cm

2. To and fro peristalsis

3. Bowel wall edema >3 mm

4. Free fluid (previously known as “tanga sign”)

Case conclusion: Patient was admitted to surgical service for management of SBO!

Happy Scanning!

• The US Team