0:02

Hello and welcome to Noon Conference, hosted by modality

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through free live educational webinars that are accessible

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and previous noon conferences by creating a free account.

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Today we are honored to welcome Dr.

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Catherine McGillen for a case-based lecture entitled Acute

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Abdominal Imaging in the Emergency Department.

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Dr. McGillen completed her radiology residency at Brown

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with a fellowship in abdominal imaging

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at Beth Israel Deaconess.

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She specializes in ultrasound

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and has recently moved to the emergency

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radiology division at Penn State.

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At the end of her lecture, please join her in a q

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and A session where she will address questions you

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may have on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

0:52

as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

0:57

McGill, please take it from here

1:00

To get started. Thank you modality.

1:01

Thanks for having me back again

1:03

and thanks to you for joining me here on this quick tour

1:07

to force for acute abdominal imaging in the

1:09

emergency department.

1:12

So some learning objectives, uh, wanna look at some tips on

1:16

how to work through weird cases when you just haven't seen

1:18

that exact thing before.

1:20

We'll look at some cases of the usual suspects,

1:23

but maybe an unusual presentation

1:25

and how to change a search pattern for emergent cases.

1:29

You'll see a lot of images by the way as we go through

1:31

that we may not necessarily go over

1:33

with just some interesting findings

1:34

that may not get discussed.

1:36

So in this particular case, we have, um,

1:38

an image from a CT scan, the scout,

1:40

where it's a football sign of just gross free air,

1:43

so much free air that it's making that football sign.

1:46

Okay, so the categories that we're gonna do one

1:48

or two cases in each one today are gonna be trauma,

1:51

hepatobiliary, gastrointestinal, gu, pelvic,

1:55

and then a little popery.

1:58

All right, so we'll start with trauma.

1:59

This one's an image of a grade two liver laceration

2:02

and an an 11-year-old after an MVA.

2:06

But here's our first case.

2:08

So we're gonna pop up for poll number one.

2:09

So please, please, please go ahead

2:11

and participate once you see it.

2:13

The background history for this is of course trauma

2:17

and what I want you to do here is put in,

2:20

type in any answers of any abnormalities

2:23

that you see on this image.

2:24

I will tell you there are certainly more than one,

2:27

but go ahead and name some one or two that you see.

2:31

Put it in the, in the app poll please.

2:54

Okay, so it looks like I can't see the

2:59

answers, but hopefully you guys can see some

3:01

of the answers that came through.

3:03

But in any case, some of the things you may have looked for

3:05

and found were abnormal density back here in the

3:09

retroperitoneum surrounding the aorta.

3:12

Um, so that would be one right there.

3:13

You'd of course need a Hounds food unit on it

3:15

to see is it soft tissue, is it fluid, is it blood?

3:18

You might also notice the IVC looks a little bit flattened,

3:21

a little bit small,

3:22

especially compared to the aorta right here.

3:24

Aorta at this point's too bright for us

3:26

to really say too much about.

3:27

There is some stranding over here, some contusive changes in

3:31

that right flank right there.

3:32

That would certainly be a little worrisome.

3:34

So in this case, we need to figure out

3:36

what this is and why it's there.

3:38

The hounds field units were around 40.

3:40

It was blood, so we needed

3:41

to figure out where is it coming from?

3:42

Is it coming from the IVC and that's why it's flat

3:45

because it's bleeding or is it coming

3:47

of course from something else such as the aorta.

3:49

That's what lives in the retroperitoneum

3:50

or any of the smaller vessels.

3:52

So at that point, what you need to do is you need

3:54

to window level if your trauma scan came over like ours did

3:57

because the aorta right now looks fine, but after you window

4:00

and level it a little bit, you'll see here

4:03

that something is going on

4:05

inside the aorta looks perfectly round.

4:07

Is that an artifact? It looks too perfect

4:09

to be a traumatic thing necessarily,

4:11

but it should definitely catch your eye.

4:13

This is a pediatric patient.

4:14

They're not gonna have any surgery

4:16

to their aorta preexisting their trauma case right here.

4:20

So if you're not sure what you're seeing, go ahead

4:23

and choose a different view.

4:24

So in this case I picked the coronal

4:26

and you can see right here we now have a flap right here

4:29

at the bifurcation level.

4:30

And this very weird thing right here as well,

4:34

a little bit more proximally in the aorta.

4:35

That's what we were seeing on the previous image, that sort

4:37

of circular thing right here.

4:40

So with that, this is a blunt aortic injury.

4:44

This is definitely a do not miss

4:45

besides the retroperitoneal hemorrhage that was going on.

4:48

You need to look at the aorta specifically.

4:51

So what this is, it's a full thickness tear at the

4:54

transected end, or in this case ends

4:56

'cause it transected in two different locations

4:59

and it's usually due to a rapid deceleration injury.

5:02

Most commonly it's occurring at the aortic isthmus,

5:05

which is obviously not in the abdomen or pelvis,

5:07

but will usually be imaged in a trauma scan.

5:10

But it occurs there near the left subclavian origin.

5:13

They think because of the ligament

5:14

and arterio it's susceptible to shear.

5:17

And so that's the most commonplace infrarenal

5:20

aorta is not common.

5:21

It's less than 10% in adults

5:22

and it's unusual in kids as well.

5:24

So let's talk about what you should be looking for.

5:27

You're gonna look for retroperitoneal blood, right?

5:29

That's definitely something you need to be looking for.

5:31

But other than that, you're gonna look

5:33

for a contour disruption

5:34

of the aorta very oftentimes, especially impedes.

5:37

The aortas gonna look pretty normal.

5:38

It takes a lot to make it look abnormal.

5:41

So you're gonna look for a contour disruption.

5:42

You're gonna look for those intimal flaps like we see here

5:45

in this particular case.

5:47

You look for a pseudo aneurysm, which is an outpouching

5:50

or of course active extravasation,

5:52

which we didn't have in this case.

5:54

And then what you're gonna do is you are going

5:56

to grade it via the Society of Vascular Surgery guidelines.

6:00

And so grade one, again, I don't have these memorized,

6:02

I look these up every time or anytime it comes up.

6:05

But a grade one is gonna be just the

6:07

intimal tear like we have here.

6:09

A grade two is also going to have an intramural hematoma

6:12

and three is gonna be a pseudo aneurysm,

6:14

which is what we have in this case.

6:16

You can see just a little bit of contour abnormality

6:18

where it sort of pooches out right here.

6:20

So this one was thought to be a grade three pseudo aneurysm

6:23

type of blunt aortic injury.

6:24

And then four is of course a rupture.

6:28

Okay, so we'll move on to our next category.

6:30

This is hepatobiliary and this was just a really neat case.

6:34

Non-contrast as you'll notice

6:35

of an emphysematous pancreatitis.

6:39

Okay, so our next poll will come up here.

6:42

So we have two different patients.

6:44

We have patient A, we have patient B.

6:46

Both are adult patients who came in with epigastric

6:49

and right upper quadrant pain.

6:50

Both had normal liver function tests

6:53

and both had a very mildly elevated white count.

6:56

So the poll question we have

6:58

for you is which image has a finding that will help you?

7:01

Sorry, which image has a finding that will be more helpful

7:04

to be more confident in a diagnosis of acute cholecystitis?

7:07

Because it will tell you only one

7:08

of these had acute cholecystitis.

7:11

So take a look at those

7:12

and which do you think it is more likely A or B?

7:26

Oh, nice. We were 50 50. I love it. That's great.

7:31

Okay, so let's talk about this case, right, so tips

7:36

and tricks for acute cholecystitis.

7:37

I think we were all aware of sort of the classic teachings,

7:40

or at least what I was taught, which is you know,

7:42

at least a mildly distended gallbladder

7:45

because it's an obstructive process so

7:46

that gallbladder cannot be decompressed, you know, it has

7:49

to be blown up like a balloon.

7:51

Um, wall thickening, maybe vascularity,

7:54

maybe not vascularity, but wall thickening, a Murphy sign.

7:56

And it turns out the wall thickening,

7:58

you can have acute cholecystitis without that.

8:00

And the Murphy sign really isn't necessarily that reliable,

8:03

especially if they've had pain medication.

8:05

So we're, I felt like I was left a lot of the time saying,

8:08

you know, could be acute cholecystitis.

8:10

You know, maybe you need further imaging

8:12

or clinical correlation to decide

8:14

and it doesn't feel good to not be able to tell them.

8:17

So I encourage you to read this article outta Radiographics

8:20

that just came out where they're improving the diagnosis

8:22

of acute cholecystitis with new paradigms.

8:25

And so I had adopted this after reading the article,

8:27

and this is a perfect example.

8:29

This case came up, you know, a few weeks later

8:31

and this is one of the findings they talk about,

8:33

which is the tensile fundus sign.

8:35

And so normally with the gallbladder,

8:37

when you put an ultrasound probe on it

8:39

or your sonographers putting that probe on it,

8:41

it will push the gallbladder down a little bit.

8:43

It'll flatten it against the peritoneal whining

8:45

or against the hepatic contour

8:47

or whatever's up against the gallbladder.

8:49

But if you have an acute cholecystitis

8:51

and an obstruction, it will be blown up

8:53

and it'll have enough pressure within it that

8:55

that fundus will not flatten.

8:57

So you'll get a little bit of mass

8:58

effect like you do right here.

9:00

So instead of this thing flattening,

9:01

following the peritoneal lining

9:02

or the liver, it sort

9:03

of pooches out really subtle, but it's there.

9:06

So this is a tensile fungicide

9:07

and if you see that you should start really thinking about

9:10

acute cholecystitis.

9:12

And then in this particular case there's a little bit

9:15

of discontinuity in the wall right there.

9:17

And that's either some sludge there,

9:18

maybe a little clot or something.

9:19

But discontinuity in the wall is also of course, um,

9:22

concerning for an acute chole cystitis.

9:25

So that being said, the article also mentions echogenic fat.

9:29

So fat is usually echogenic anyway,

9:31

but when it's inflamed it gets more epigenic.

9:34

I personally still struggle with this one

9:36

in trying to identify this.

9:37

You can't account, you know, for the increased

9:40

through transmission behind the gallbladder to count

9:42

as the epigenic fat.

9:43

Um, but they talk about that as well.

9:45

And then if you're doing doppler

9:46

and duplex, uh, ultrasound imaging

9:49

and if you can teach your sonographers

9:51

or yourself to find cystic artery,

9:53

if you're finding a peak systolic velocity greater than 40

9:55

centimeters per second, that's another indication

9:58

of acute chole cystitis.

10:00

And again, this is in addition to the classic things

10:03

that we talk about and that we look for, you know,

10:05

the wall edema, the thickening and the positive Murphy sign.

10:08

In this particular case, the Murphy sign was negative

10:11

and you can see there really is no wall thickening here.

10:13

It was nice and thin, but because of that tensile fungicide

10:16

and then discontinuity in the wall here,

10:18

which may be why the Murphy sign was negative to be honest,

10:21

um, we were able to suggest

10:22

that this was acute cholecystitis.

10:24

They went to surgery and then it was proven intraoperatively

10:27

and on pathology that it was a marked quote unquote acute on

10:30

chronic cholecystitis.

10:32

So here's some different images.

10:33

This is the patient B that I showed you.

10:37

So this one's a little bit more subtle.

10:38

You might say, well that's a little pooching out there

10:40

of the fun to, of the gallbladder.

10:42

But what's not there is,

10:44

here's your peritoneal lining right here.

10:46

You know the liver right here, the peritoneal lining,

10:48

the peritoneal lining is flat.

10:49

There's no mass effect on

10:50

that fundus against this right here.

10:52

If you're not sure and you have the option

10:55

to have cine clipse get cine clipse of the gallbladder,

10:57

I think it really, really,

10:58

really helps in these kind of cases.

11:00

And so in this case we flipped and now we're transverse.

11:03

And you can see the bright peritoneal lining right here

11:07

and it's now has mass effect upon the gallbladder, right?

11:09

It almost dips down just a little bit.

11:11

The gallbladder is certainly not pushing it, uh,

11:14

or pushing up against it.

11:16

Another case right here in this case,

11:18

the liver comes across right here

11:20

and actually pushes down on the gallbladder.

11:22

So between just the peritoneal lining itself, the,

11:24

the weight of the liver

11:26

and of course that probe pressure right there is telling you

11:29

this is not a tensile fun toine here.

11:33

And then this is another case of acute cholecystitis.

11:35

So in this case, I show it to you

11:36

because I don't want you to get fooled

11:38

by the reverberation artifact that you see right here.

11:40

You certainly had stones,

11:41

there wasn't really any wall thickening necessarily,

11:44

but very subtly it just pushes up peritoneal whining if you

11:47

follow all across, should be down here

11:49

and it's not, it's a little bit higher

11:51

up pushes up right there.

11:53

So this one, um, was also surgically confirmed case

11:56

of acute cholecystitis.

11:58

And again, I would encourage you to look in different planes

12:00

to see if you think that's real, that little pooching out

12:03

or if you think that it could just be artifact,

12:05

Dr. McGillan, a

12:06

quick, uh, note if you're using a cursor,

12:09

we can't quite see that, so I'm not sure if you,

12:11

Oh, I'm sorry. Oh, there

12:12

it is. Perfect. Yep, there it is. Wrong one.

12:13

So sorry, right here. So follow across right here.

12:16

There's that little pooching out right

12:18

there just a little bit.

12:19

I would expect that to go right under

12:21

here and it didn't, right?

12:24

So again, using different, different views to confirm that.

12:26

Going back here, just to show you those quick cases again

12:29

since I was on not using the cursor correctly,

12:31

a little outpouching right there, right?

12:33

Should have followed maybe along right here.

12:35

Should have flattened right there. And it did not.

12:38

This case here. Peritoneal lining straight across, right?

12:41

So even if there's an outpouching right there straight

12:43

across, no mass effect, not a tensile fundus.

12:45

Again, right here it's flattened

12:47

and right here even comes down right there.

12:50

Thanks for, thanks for pointing that out. Okay.

12:55

And then this is sort of just the CT correlate.

12:57

It's not quite the same thing

12:59

because there's no probe pressure.

13:01

You know, if you're pushing down

13:02

and something doesn't flatten,

13:03

that's a much more sensitive sign that

13:05

that gallbladder is under pressure.

13:07

Um, but this case was so flagrant

13:09

that I thought it was a nice example if, if it's bad enough,

13:12

you'll see it on CT scan where you can see

13:13

that gallbladder really pushing anteriorly on

13:16

that peritoneal lining right there don't even see

13:19

necessarily a lot of stranding other CT signs

13:21

of acute cholecystitis.

13:23

But that pushing right there would certainly suggest to me,

13:25

um, that should have flattened out

13:26

with the weight just at the, you know, the skin,

13:28

the subcutaneous fat, et cetera.

13:33

Okay. All right, next case.

13:37

So this is another ultrasound.

13:38

This patient is 46-year-old female,

13:41

right lower quadrant pain is what they said specifically.

13:44

Um, they actually started with the CT scan,

13:46

which I'm not showing you yet.

13:47

CT called no change.

13:49

I won't tell you what the no change was about yet.

13:51

Um, but then they got the right upper quadrant ultrasound

13:54

specifically for an elevated T bilirubin

13:57

and a history of liver disease and for pain.

14:01

So as I was talking there,

14:03

hope you were looking at this image

14:04

and my question for you is no poll here,

14:06

but just sort of thinking what image would you want next?

14:09

Not what study, but what particular image would you want

14:12

your sonographer to give you next

14:13

or if you were scanning yourself.

14:15

If that's the case, you're looking at all these koic

14:17

branching structures and you don't know

14:19

what they are at this case,

14:21

what you really need is a doppler image.

14:23

So with that gives you a little bit more information about

14:26

what we're looking at here.

14:28

So we can see that one of those branching structures is the

14:30

portal vein right here, flow going into

14:32

the liver as it should be.

14:34

And then you have this koic thing directly anterior to it.

14:37

It's not, you know, varix or really dilated hepatic artery.

14:41

It tells you that this is an avascular structure.

14:43

This is gonna be the dilated common bile duct.

14:45

So now we know we have extrap pad, biliary dilation,

14:49

probably some intrahepatic biliary dilation

14:51

'cause this doesn't look like it's filling in either.

14:54

Get some more images here.

14:55

And now we can see this is the portal vein right here.

14:58

Don't have the color doppler on this time,

14:59

but this is the portal vein just to orient you.

15:01

I know it's labeled uh,

15:02

gallbladder fossa, but ignore that for now.

15:05

This structure right here was the common bile duct.

15:07

And you can see right here there's an abrupt

15:10

narrowing right there.

15:13

So again, if you had sending clips, you could certainly scan

15:15

through them and make sure that you believe

15:16

that was really what you're seeing.

15:17

It wasn't just volume averaging

15:18

or the depth diving off somewhere,

15:20

but that is an abrupt narrowing right there.

15:23

So based off of that alone, the next question I would have

15:26

for you is what else do you need

15:28

to do In this case I told you they'd already done a ct.

15:30

So I went back and looked at the CT myself

15:33

that had already been read

15:34

and this is your coronal image right here,

15:36

portal being really bright right now.

15:38

But you can see that dilated common bile duct.

15:40

And what I want you to really notice right here is this

15:43

enhancement of the wall of the duct.

15:46

Normally the the bile ducts don't really enhance much.

15:48

You almost don't see the walls at all for the most part.

15:51

So when you see them, you should pause for a second

15:53

and think, you know, is this normal?

15:55

Is this tumor? Is it inflammation or infection?

15:58

Um, and then of course we can also see the int hepatic

16:00

biliary dilation, which I think is easier

16:01

to see on the CT than it often is on ultrasound.

16:05

So with that being said,

16:07

we now know we definitely have biliary dilation,

16:09

we have abnormal enhancement here.

16:11

So there's probably something acute going on given

16:13

that her LFTs are abnormal.

16:15

So what do you do next? What should you recommend?

16:19

And in this case, they ended up getting an MRI with MRCP,

16:23

which I think turned out really nicely.

16:25

Um, you can see int hepatic build gel,

16:27

you can see an abrupt cutoff right here.

16:29

You can see the distal common bile duct looks pretty normal

16:32

caliber right here.

16:33

So that's your MRCP image. Um, so tips and tricks.

16:37

This is a CBD stricture, um,

16:39

or I guess a common hepatic duct stricture.

16:42

What you're looking for in ultrasound,

16:44

I find the T tram track sign to be the best

16:47

way of seeing it.

16:48

Um, because you have your portal triad, right?

16:50

You have your portal vein, you have your hepatic

16:52

artery and you have a bile duct.

16:54

Normally on ultrasound in the liver itself,

16:56

you're really only seeing the portal

16:57

vein out of those three.

16:59

So if you're seeing two things traveling together,

17:02

it's more likely to be a dilated common

17:04

or a dilated bile duct along with that portal vein.

17:07

So, and that creates this, you know, tram track sort

17:09

of appearance that you can see you right here,

17:11

this is probably your vessel

17:13

that you can't tell without doppler

17:14

and you have a structure right next to it.

17:16

Doppler is gonna help you to prove that that's the case

17:19

and it's not just, you know,

17:20

hepatic vein going by for example.

17:23

And then the next thing I wanna talk about here is Mr

17:25

RCP versus ER CP.

17:27

In my case we did get the MRCP,

17:29

but I would argue if the patient's gonna get an ER CP

17:32

anyway, you can certainly consider just skipping the MRCP

17:35

recommendation because we already knew they had biliary

17:38

dilation, we knew there was abnormal enhancement,

17:40

they had abnormal LFTs and pain.

17:42

This person was going to get an ERCP regardless,

17:45

the MRCP really didn't help.

17:47

Um, so in a case like this, if GI wants it, you know,

17:50

to look for anatomy or to look for some sort

17:52

of metastatic disease in the area,

17:53

that might change their management, they'll ask for it.

17:56

But otherwise, I don't think you necessarily

17:58

have to recommend it.

17:59

If you know, ERCP really is the next step.

18:02

So I'll show you this image as well.

18:03

Just another view of a tram track

18:05

appearance of biliary dilation.

18:07

You won't see it everywhere.

18:09

You have to actually look for it

18:10

because it all depends on what plane you're in,

18:12

whether you're gonna see it or not.

18:14

And this is the patient, again, this is their ER CP image.

18:17

Um, you can see the really narrow stricture right there.

18:20

This patient, um,

18:22

it was a post-inflammatory stricture in their case

18:24

it was not malignant.

18:25

The biopsies were negative for that.

18:27

There were no signs of infection.

18:29

Um, but they'd had a really raging acute cholecystitis a few

18:32

years ago and um,

18:33

she just has a stricture there because of it.

18:35

That just keeps sort of narrowing back down.

18:39

Okay, and then we will move on next to the GI tract.

18:43

So another scout image from the CT scan shows a lot

18:47

of abnormal bowel, but we have our coffee bean sign here,

18:49

so, which is a classic, uh, sigmoid ulus.

18:55

Okay, so poll number three.

18:58

This is a 79-year-old female who's coming in

19:01

with left lower quadrant pain.

19:03

They do have an elevated white count of 22.

19:06

So the question in this poll for you to consider is,

19:09

do you think this is an acute diverticulitis yes or no?

19:13

So please answer yes or no whether this is an

19:15

acute diverticulitis.

19:16

And then I want you just to sort

19:18

of think about why you think it might be

19:19

or why you think it might not be

19:36

all right.

19:36

So not quite 50 50 but pretty darn close.

19:40

So a lot of people thought this was acute diverticulitis

19:42

and a lot acute diverticulitis and many did not.

19:46

I will say that this was initially called an acute

19:48

diverticulitis when it was red.

19:51

So some of the imaging findings

19:52

before we talk about what it ended up being

19:54

is we have inflammation here along the

19:57

descending colon, right?

19:58

Definitely inflammation,

19:59

definitely centered around the colon.

20:01

We have a little bit of thickening

20:03

of the paracolic gutter right here.

20:04

Again, just objective signs

20:05

that there's an acute inflammatory process going on in this

20:09

location and it's certainly centered around the colon.

20:11

So we know there's something acute going on there.

20:13

Um, beyond that, I'll give you a second image

20:16

because I really do think I'm a big believer in,

20:18

once you see something and you're not a hundred percent sure

20:21

what it is, go to a coronal, go

20:22

to a sagittal if you're on ct.

20:24

So in this particular case,

20:26

there's a little bit more information right here, uh,

20:28

on our coronal here you can see that there's gas

20:31

surrounding the colon sort of infiltrating in almost like a

20:34

pneumatosis, um,

20:36

contained within the pericolic gut at this point,

20:37

but extending sort of upwards as well.

20:40

And then what you'll notice here too is this structure right

20:43

here, certainly asymmetric to the right colon,

20:45

but this guy right here, so you have this hyperdense thing

20:49

in the colon sort of laminated appearance

20:51

with these different sort of layers

20:53

and it looks different than the rest

20:54

of the stool does, right?

20:55

And that's really where the inflammation was sort

20:57

of centered around here with the gas tracking back up

21:00

the colon in this case.

21:02

And one thing I I will definitely say is if you look at the

21:05

colon, we really don't see any

21:07

diverticuli in this field of view.

21:09

So I'm not seeing any normal ones,

21:11

just ones living there not being inflamed or being angry

21:15

and I'm not definitely not seeing a focal thickened

21:17

diverticulum to account for this.

21:19

So in this particular case, this was a stir coral colitis.

21:23

So what you look for in these kind of cases are

21:26

that laminated dense stool ball.

21:28

They're gonna be denser than normal stool

21:31

and they're often gonna have a laminated appearance like

21:33

this one does right here as it sort of just forms.

21:35

And it's this rock hard stool ball.

21:38

We're used to seeing it most commonly in the rectum

21:40

with a big stool ball that may or may not be rock hard,

21:42

but just these giant stool balls

21:44

with surrounding inflammation.

21:45

But they can occur elsewhere in these two different cases.

21:49

Um, they can obstruct if they get big enough in this case

21:53

you can see this one again in the descending colon,

21:55

but this huge stool burden more proximally here

21:58

and then a transition point right below it.

22:00

So this one was actually causing an

22:02

obstruction at this point.

22:05

Um, and lastly I wanna say too, beware

22:08

of calling an acute diverticulitis.

22:10

If you don't have the diverticulum,

22:12

sometimes you really do have so much inflammation

22:14

and it absolutely could be a

22:15

diverticulitis and you just can't tell.

22:17

But in these two cases, um,

22:19

there were no diverticuli elsewhere

22:21

and we definitely didn't see a thickened

22:23

or inflamed one in the area.

22:25

And it's really, really important, right?

22:26

Because they're treated completely differently.

22:29

Acute diverticulitis versus aster, coral colitis,

22:32

the stir coral colitis, this thing can obstruct

22:34

and eventually perforate, which is

22:35

what happened in this case stool everywhere.

22:37

Surgeons have a really hard time giving every

22:40

single bit of stool out.

22:41

These patients then come back

22:42

with recurrent abscesses all the time,

22:44

it's really, really bad.

22:45

Um, but the other thing that can happen too

22:48

besides obstructing

22:49

and perforating is the stool ball itself can get so big

22:52

that it ends up, um, putting a lot

22:55

of pressure on the wall adjacent to it

22:57

and then it causes uh, like a local ischemia

23:00

and an ulceration and then it can perforate there.

23:02

Cause a lot of adhesions. So it can be a lot of badness.

23:05

So you really have to recognize if you see it,

23:07

and again, it's usually gonna be a really dense stool ball,

23:09

often laminated like this.

23:11

And the inflammation is actually gonna be centered

23:13

around the stool ball itself

23:15

because that's where the ulceration is starting to occur.

23:18

So you look for that. Okay,

23:22

we'll move on to our next case then.

23:26

So I'll let you sit with this image right here.

23:28

This is a 44-year-old.

23:30

She came in with abdominal pain,

23:32

which is the history that was given.

23:34

And so the poll question in this particular case is gonna

23:37

be, do you think this is more likely a duodenitis

23:41

or a pancreatitis given the,

23:44

the images that you have right here?

23:45

No labs, just images.

24:03

Okay, duodenitis 77%. Great.

24:07

Okay, so that is what it was.

24:10

It was a duodenitis and so we'll let's talk about this.

24:13

What are we looking for? They can present in different ways.

24:15

So thinking about all the different ways it can present can

24:19

help you to diagnosis in the acute setting.

24:21

So we'll back up just for a little bit

24:22

and we'll use this illustration to sort of remind us

24:25

of the anatomy of what we're seeing here

24:27

because depending on where the ulceration is, is going

24:31

to help decide what you're seeing, where the air is,

24:34

if there's air that perforated out,

24:35

where the inflammation is, um, where the fluid is.

24:40

So of course we're gonna look for wall thickening

24:42

of you know, the duodenal bulb, the distal stomach

24:44

or the second part of the duodenum,

24:46

which are the most common places for this to occur.

24:48

You're gonna look for the wall thickening,

24:49

usually circumferential,

24:51

but we also know that in a bad enough acute pancreatitis you

24:54

will get reactive wall thickening.

24:56

But again, we're looking to see is it centered

24:57

around the duodenum itself.

24:59

You're also looking for stranding

25:01

and free fluid in those particular areas

25:04

and you might see free air if it has perforated.

25:07

So given what we know of anatomy, you're gonna look for two,

25:10

uh, two places that are gonna help you decide is the

25:12

duodenum versus somewhere else.

25:14

And I'll pause for just a second before we talk about that

25:16

because it is important, um,

25:18

for which surgeon is gonna operate.

25:20

You might just say, oh free air, it's a surgical issue.

25:23

But it is super helpful for the surgeon, number one to know

25:26

and have an idea of where they're gonna look first.

25:29

Um, but you know, in my institution at least if it's a colon

25:32

perforation that's going to a colorectal team.

25:34

Whereas if it's a duodenal or a stomach

25:36

or even a small bowel, um, acute process, it's gonna go

25:39

to our emergency general surgeons.

25:41

So again, it's helpful to get them

25:43

to the correct surgeon at the right time.

25:45

So we're gonna look for free air patterns if they have it.

25:48

If you see pi, uh, right perren in this area here

25:52

or anterior pararenal right here,

25:54

that is gonna be usually a second portion of the duodenum

25:58

or very distal bulb because it's gonna be more

25:59

of a retroperitoneal process.

26:01

So the free air that occurs up here isn't helpful

26:04

because that's just accumulating there.

26:05

So I like to look for air in weird places that it shouldn't

26:08

otherwise get to with gravity.

26:11

And these are two really good locations to look at.

26:13

So if it occurs in either of those two locations,

26:15

you should really be thinking it's the

26:17

duodenum that is causing that.

26:19

On the other hand, if it's the stomach

26:20

or the very proximal bulb,

26:21

you might get more intraperitoneal free air

26:24

because it's gonna perforate out here

26:25

and it's gonna release into the space right here.

26:30

Okay, other things to look for. This is a coronal case.

26:33

Um, you can see a lot of free fluid in this particular case.

26:36

We have some gas, you know, in weird places right here,

26:39

but you're gonna look for wall discontinuity

26:41

and you won't necessarily just see it on the axial image.

26:45

You might only see it on the coronal or maybe the sagittal.

26:47

So if you're not sure, again use all

26:49

of the information that you have.

26:51

And in this case you can see

26:53

I think a pretty obvious wall discontinuity right there in

26:56

the fluid just coming out of it.

26:57

You're not always that lucky to see that big

27:00

of a gap in the wall.

27:02

But again, if you're not looking for it, you don't see it.

27:06

Here's a few, uh, additional cases.

27:09

So I'll let you sit with those for a second as well.

27:12

Again, this is all duodenitis slash ulceration,

27:17

but here is an example of a cleft sign right here,

27:20

which I think we're pretty subtle

27:21

and I think they're very easy to miss

27:24

unless you are specifically looking for it.

27:26

So if you scroll through these cases,

27:27

that's only gonna be on one

27:29

or two slices, you're not gonna see it,

27:31

just your eye's just not gonna pick up on it

27:32

unless you are specifically looking for it.

27:34

And here it is right here. Again, that cleft sign,

27:37

you might not see it go all the way through the mucosa,

27:39

but that doesn't mean it's not there.

27:41

So if you see it, you can suggest

27:42

that this is most likely coming from the duodenum, they go

27:45

to the EGS instead of colorectal.

27:47

If you're wrong, you're wrong.

27:48

But I found this cleft sign, uh,

27:50

has saved me a lot of different times.

27:54

Um, let's see.

27:56

So we already talked about if it's from the stomach,

27:58

you're gonna see a lot more free air.

28:00

In this case it was probably bulb right here.

28:02

So we do actually have free intraperitoneal air.

28:05

So again, it's not gonna work a hundred percent of the time,

28:07

but you use your clues when you have them,

28:09

whether it's air in a weird place

28:11

or looking for a cleft or something like that.

28:14

Okay. All right,

28:17

and one more case right here, just another example of it

28:20

where this wasn't a sign that I'd heard of

28:22

so I was not looking for them,

28:24

but this, okay, this was the original case.

28:26

There is your cleft sign right there.

28:28

Very subtle, but there it is.

28:29

It blends into the fluid all around it right here.

28:31

So again, if you're not looking, you're not gonna see it.

28:34

I do think it looks different than just um, the folds

28:37

of the duodenum right here,

28:38

which can be a little bit irregular, they can be linear,

28:41

but these really do look like a little V when you see them.

28:43

And again, that's gonna suggest it a little free fluid over

28:46

here and then a little free air over here.

28:49

And again, this wasn't a pancreatitis

28:50

because from what I showed you of the pancreas,

28:52

at least you know, the fat next to it is really quite clean.

28:55

There's no inflammation there, nothing there to suggest that

28:57

that was an acute pancreatitis.

28:59

The inflammation was really centered here around the deum.

29:04

Alright, so continue to move on. So let's go to gu.

29:11

Okay, so we can bring up pole number five.

29:14

This is a 76-year-old female.

29:16

She has a history of primary sclerosis cholangitis.

29:20

She's presenting with pain

29:22

and six weeks of worsening lethargy.

29:25

She's a little bit of background dementia too, which is um,

29:29

I think useful information.

29:30

So what is your best diagnosis based off

29:32

of the image that I showed you?

29:33

Do you think this is more likely a renal malignancy

29:36

or do you think it's more likely an abscess?

29:53

All right, so abscess great.

29:56

We have 80% picking abscess, that's what this was.

29:59

Um, but this is a tricky case again,

30:01

which is why I showed you.

30:02

And this was initially prelims as uh, a mass.

30:06

I think because of all of this weird,

30:08

almost like soft tissue likes subtly enhancing stuff right

30:11

here that they thought this could have been, you know,

30:14

like a, a necrotic or a cystic tumor.

30:17

So in a case like this, what do we

30:19

do next if we're not sure?

30:20

Let's look for secondary signs.

30:21

Let's look in different views.

30:22

Let's try and figure out what this is.

30:25

And of course we can certainly do some clinical correlation

30:27

ourselves if we need to.

30:29

So in this case, I think a reasonable differential.

30:32

This also would've been evolving hematoma, um,

30:35

especially if they had a relevant history.

30:37

Did they have trauma, did they have a bleeding disorder?

30:40

Anything like that that would make you think hematoma.

30:42

Um, but what we're seeing here is mass

30:44

effect on the kidney, right?

30:45

Here's your kidney and it's being squished.

30:48

So this is a page kidney

30:49

or developing page kidney which occurs

30:52

by extrinsic compression, uh, sorry,

30:55

extrinsic compression on the renal parenchyma

30:58

by a subcapsular process.

30:59

And you can certainly see that how this is sort

31:01

of contained right here.

31:02

Not all of it, but a lot of this is contained.

31:04

So this is a subcapsular process.

31:06

Um, and you can see some heterogeneous enhancement

31:08

of the liver, sorry, the kidney as well.

31:11

So this is a page kidney, this is an extrinsic process.

31:14

I did not think this was coming from the kidney.

31:16

I did not think this was a claw sign.

31:18

I think this was pushing on it.

31:20

But again, if you're not sure,

31:21

definitely dive into the chart

31:23

or if there's nothing available yet, if

31:24

that patient's too sick, they don't have

31:25

labs or anything yet.

31:27

Um, ask for the correlation.

31:29

This patient ended up having a leukocytosis

31:32

and a positive urinary analysis

31:33

looking like it was infected.

31:35

So that made it a whole lot easier once you look

31:37

and notice that stuff and didn't just

31:39

rely on the history they gave us.

31:41

So in this case, uh, back up for a second, um,

31:44

they did end up going for a drain.

31:46

They originally could be scheduled for a biopsy,

31:47

but we called them in the morning and said this

31:49

isn't a mass.

31:51

Um, but the procedure itself, if you're doing it via CT

31:53

or ultrasound guidance is almost the same anyway.

31:55

You put a needle into it.

31:57

If you get pus out then you know you've confirmed this is an

31:59

abscess, you put the drain in.

32:00

If you're not getting much out then you can certainly just

32:03

do a core biopsy right through that same area.

32:05

But in this case they did go for the drain.

32:07

Um, they got past it grew out e coli

32:09

which matched the urine culture.

32:11

The white count went from 23 back down to 11 within a day

32:15

and they actually drained almost 1.3 liters in the first 24

32:19

hours after the drain, which is absolutely crazy.

32:22

So again, other things that we were thinking of, um,

32:25

it was initially called uh,

32:26

soft tissue mass in a renal cell carcinoma potentially.

32:29

And what you're looking for is a claw sign in this

32:32

particular case, you can see this almost claw right here

32:35

of renal parenchyma surrounding this RCC

32:38

and that's what you're, you're looking for as opposed

32:40

to this case where you could almost think it's a claw sign

32:43

but really it's this thing pushing the kidney away.

32:46

It's not coming from the kidney in this case.

32:49

And I think just looking at a lot of these kind

32:51

of cases will help you see the

32:52

subtle differences between them.

32:54

So even though you're still like, you know,

32:55

is this soft tissue, this is probably just tissue

32:57

that hasn't necros and become um, pus yet.

33:01

So again, differential is certainly reasonable clinical

33:03

correlation and then ultimately you're gonna put a

33:05

needle into it regardless.

33:08

All right, so we talked about the cloth sign there

33:10

and then again unsure get the UA

33:13

or check the UA yourself, see what it looks like.

33:15

And then aspiration

33:16

or biopsy is ultimately gonna be the management of something

33:19

that's this large anyway, okay,

33:23

next case we're gonna pop the pull up on this one.

33:25

This is a 26-year-old female, she's presenting

33:28

with pelvic pain and she has a fever and is tachycardic.

33:32

She is three weeks post and xla for endometriosis.

33:37

Just you know, to complicate things a little bit,

33:39

we got a nice, nice history in this case.

33:41

So do you, what do you think the

33:42

best diagnosis is in this case?

33:43

Is this a plon nephritis of a pelvic kidney

33:47

or are these renal infarcts?

34:01

Right, most of us are voting for plon nephritis. Great.

34:04

So that's what this was.

34:05

But I personally think telling the striated neph gram

34:09

of a pyelonephritis from an infarct can be pretty

34:12

tricky on imaging.

34:13

So we're gonna talk about some of the tips

34:15

and what you can do um, to help decide what you think it is,

34:19

especially if labs aren't available yet.

34:21

So she was post-surgical so she was certainly at risk

34:23

for clotting something off getting infarcts,

34:25

but she also was post-surgical

34:27

and was at risk for an infection,

34:28

especially since her surgery was in the pelvis itself.

34:31

She happened to have a pelvic kidney.

34:33

But what we are seeing here is our stri in nephro grand

34:35

with hypo enhancement right here.

34:37

Um, she did get a urinary analysis, it was positive

34:39

for nitrates, tase and bacteria,

34:42

but her white count was only 12.

34:44

So again, it was one of those where you're like,

34:46

is it or is it not?

34:47

Um, but she did have pelvic pain

34:49

and so we called this a pyelonephritis.

34:52

So tips and tricks for diagnosing one versus the other.

34:56

I really think it can be hard right here.

34:58

So I have two columns here of different cases.

35:01

Um, this column here are pyelonephritis nephritis cases,

35:04

this column here, these are all infarcts

35:06

and I think that there is really some overlap right here.

35:09

So see these are uh, some of the things you can look

35:11

for the enhancement I find that pilo tends to hypo enhance,

35:15

which again, if you're looking at one patient,

35:16

how do you know if it's hypo enhancing versus very hypo

35:19

enhancing or almost not enhancing?

35:22

Um, ality. Pilo can be solitary, can be a, you know,

35:26

a focal pilo nephritis

35:28

or it can be multifocal like the strided nephro gram down

35:30

here infarct, same thing though, right?

35:32

It can be one infarct, you know like right out here where

35:35

that's one really big solid infarct

35:37

or it can be multifocal like you know all these right here

35:40

which sort of mimic that Stri Nephro Graham,

35:42

you can have inflammation surrounding the kidney, right?

35:45

And that can absolutely happen in a pile of nephritis.

35:47

You expect it but it's not always there.

35:50

Um, renal infarct is an acute process.

35:51

Could that get a little bit of inflammation

35:53

and absolutely could.

35:54

So I don't think that's a really great

35:56

differentiator either.

35:58

In pilo you often get enlargement of a kidney, um,

36:02

that is gonna be less common in a renal infarct

36:05

but you don't always get enlargement of that kidney.

36:07

So I think that one is a little bit

36:08

or can be difficult as well.

36:10

And then I like to look for secondary signs

36:13

whenever I'm making a diagnosis.

36:14

So if it's an ascending pyelonephritis,

36:17

you might have thickening

36:18

and enhancement of vi urothelium which

36:20

sort of like a bile duct.

36:21

Oftentimes you can't see the

36:22

wall, you can't measure the wall.

36:24

So if you can see it because it's enhancing

36:26

that might be an ascending urinary tract infection,

36:28

then you're like ah, pyelonephritis.

36:29

That's what this is. Whereas renal infarct,

36:32

if you're seeing those, you of course wanna look

36:33

for other infarcts elsewhere, splenic infarcts, um,

36:37

you wanna look at the vessels

36:38

to see if you can see something

36:39

that is actually is they're clot in there,

36:41

is there an injury to the vessel

36:42

that could be causing these

36:43

infarct, which will help you be sure.

36:45

But that being said, there really is a lot of overlap

36:46

and in just my own personal experience, I have found this

36:51

to sort of be the best indicator.

36:53

And again, if it's one patient,

36:55

how do you know hypo versus very hypo?

36:57

But I would argue even in these examples right here,

37:00

the hypo enhancement of pilo is often subtle

37:03

and just you almost have to window level it

37:05

to be like, is that really real?

37:06

Whereas a renal infarct, they just tend to be darker,

37:10

they almost tend to match the fat adjacent to it.

37:12

They're so dark, not always,

37:13

it's not always gonna work that way.

37:15

But again, if you're not sure right,

37:16

you just get the urinary analysis,

37:18

that's gonna be your next step.

37:19

You're gonna see if it's positive or not.

37:22

Um, in this particular case I only talked about pilo versus

37:25

infarct, but something else you might need

37:26

to consider as lymphoma.

37:28

'cause lymphomas can look like anything they want

37:30

to generally not like this.

37:32

But in the, uh, I'm gonna go back right here in a case like

37:35

this where they almost look rounded in mass, like

37:37

that could have been a lymphoma

37:38

as well in the appropriate clinical scenario.

37:41

So I just wanna throw that one out there.

37:44

Okay, so we will enter the pelvis here.

37:46

I've got a bunch of images here.

37:47

This one was a penile fracture where you can see um, loss

37:51

of architecture right there and some inflammation in

37:53

that T two weighted image.

37:54

This one is an infarcted, right testicle.

37:56

We have blood flow on the left but not the right

37:58

and then we have a slightly atypical hemorrhagic cyst

38:01

with the lace like reticular echoes

38:02

but the clot hasn't retracted yet,

38:03

so it almost looks like a mass

38:05

but no vascularity internally.

38:08

So with that being said, let's go to our first case here.

38:10

So this is a 25-year-old

38:12

and she's coming in with pelvic pain.

38:14

So this is your image of the right ovary.

38:16

A lot of images here. So I'm gonna move

38:17

through relatively quickly

38:19

and then we'll go over the findings.

38:23

All right, so this was a transverse image just

38:25

to orient you quickly, this is the uterus right here

38:28

and you can see the sonographer in this case was measuring

38:30

something posterior to the uterus

38:35

and we moved on to the left ovary,

38:38

left AA again uterus up here with increased

38:40

through transmission from the endometrium right there.

38:44

Okay, so those are your sets of images.

38:46

So again, 25-year-old came in with pelvic pain

38:49

and when you dug into the chart, uh,

38:50

there's really great note in there

38:51

that said she was recently treated empirically for a UTI.

38:55

Her boyfriend had tested positive for chlamydia,

38:58

she was treated empirically but didn't take the full course

39:01

and then came in a little bit later for um, pain.

39:06

So she didn't end up testing positive for PID presumably due

39:09

to partial treatment, but she's all the

39:11

imaging findings of it.

39:13

So they treated her again for um,

39:15

for a complete treatment of it.

39:16

So in this case what we're looking for, right ovary,

39:19

we have this peripheralization of follicles,

39:21

which is very not specific, right?

39:23

You can see that in a TORS ovary.

39:25

You can see that in polycystic ovarian syndrome,

39:27

but you can also see it in a PID of A.

39:30

So that's what we're looking at here.

39:32

We're also seeing this complex fluid

39:34

that could just be blood but it could also be pus.

39:38

But it's not just the physiologic normal free

39:40

fluid that's simple, right?

39:41

There's complexity to it.

39:42

And then you have these striations, right?

39:44

Those are gonna be adhesions,

39:45

which we should not really see.

39:47

Um, normally next.

39:50

Moving over to the left,

39:51

we can see the sonographer here was

39:53

measuring this thickened structure.

39:54

Sonographers gonna sit on this,

39:56

they're gonna see if it peristalsis.

39:58

This thing did not perol so they knew

40:00

that it was not bowel, which is back here.

40:02

So you have this thickened tubular structure

40:04

that they could follow and it went to the left ovaries.

40:06

So we thought this was a thickened fallopian tube

40:08

with some complex internal fluid.

40:13

And then lastly on the left here, the ovary,

40:16

this one again lots of peripheralized follicles

40:17

looks a little bit big, right?

40:19

It's almost the same size as the uterus there.

40:21

And this was the thickened tube in a different plane right

40:23

here where again you can see very thickened wall complex

40:26

fluid internally.

40:28

So we were able to confidently make a diagnosis of PID

40:32

or pelvic inflammatory disease.

40:33

So I think this is a hard diagnosis

40:35

to make on ultrasound if they aren't telling you that

40:37

that's what they're looking for.

40:38

And oftentimes they won't be telling you that necessarily

40:41

because they might image before they've done a pelvic exam.

40:44

So what you should look for, look for geographic distortion

40:47

where things just aren't where they should be

40:48

or they don't look like they're moving.

40:50

Um, if your sonographers are comfortable doing push

40:53

maneuvers, you can look at the normal anatomic structures,

40:56

they should separate when you push on them.

40:59

But if they are ahe,

41:00

then they will not necessarily move apart.

41:02

You can also look for abnormal vascularity When things are

41:05

inflamed, the vascularity should go up.

41:08

Um, differential. In a case like this, everything

41:10

that we just looked at could absolutely be endometriosis,

41:14

not an endometrioma, but endometriosis.

41:17

That could have been blood, those could have been adhesions

41:18

due to endometriosis.

41:19

This could be a um, hemato cell pinks.

41:23

But again, clinically you're gonna decide what that is.

41:27

So I will say that PID is a spectrum.

41:29

You may see some of the findings, you may see one

41:32

of the findings, but this is what you're looking for, um,

41:34

generally in this order is how it happens

41:37

because first you're gonna get infection

41:40

and then oftentimes what you're gonna see first imaging wise

41:42

is the sal meningitis.

41:43

So you're gonna see a thickened fallopian tube

41:46

may have some complex fluid in it like this one does,

41:48

which is gonna be the pus.

41:50

The tube is should be um, increased vascularity,

41:53

but you're not always gonna see that.

41:54

So pues going through the tube causing the inflammation

41:57

starts spilling out over the ovary

41:59

and that's when you get the ERUs.

42:01

So the ovary is gonna enlarge,

42:02

it's gonna have these like peripheralized follicles

42:04

and it's gonna be vascular, which is

42:06

what was happening in this particular case right here.

42:08

Um, um, my marker went,

42:10

this was the right ovary, not the left.

42:12

Um, ovus as that pus is sort of spilling out over

42:16

that ovary, you're then of course gonna get free fluid,

42:18

which is going to be the pus.

42:20

And because pus isn't good,

42:23

you are gonna start forming these adhesions out here,

42:25

these septations um, surrounding the ovary.

42:29

You then eventually because of all that inflammation,

42:31

you get the peo cell pinks where you can actually see it

42:34

and it's gonna start getting those adhesions

42:36

and it's going um, block the tube

42:39

and that's when the tube really blows up

42:41

and you get like a full fledged uh, cervical

42:43

or not cerv serpentine PIO cell pinks.

42:46

And then from that, when

42:48

that progresses you can get the tubo ovarian complex

42:50

where the ovary and the tubes sort

42:53

of all fuse in this big inflammatory infectious process.

42:56

And you get the tube ovarian complex,

42:58

which if you have it long enough forms an abscess.

43:01

And that's what we had in this case. So geographic

43:02

distortion, can't find a normal ovary,

43:04

can't find a thickened tube.

43:05

It's just this big inflammatory process right here.

43:09

So that is what you can look

43:11

for in PID whole spectrum of findings.

43:15

All right, next case here, no pole,

43:18

but this is a 33-year-old man presenting to the ED

43:22

with swelling and pain

43:24

and we wanna rule out torsion or hernia.

43:27

So I'm gonna have you look at that for a second right here.

43:29

Oops.

43:39

Okay, so as you're looking through that,

43:41

hopefully you immediately saw

43:43

that the left is clearly asymmetrically abnormal, right?

43:46

It's very, very heterogeneous if you're just looking at this

43:49

image, we often call it the buddy view.

43:50

It should be two in the same view if you can.

43:53

But the most important part is all of the um, ultrasound,

43:58

it has to be done the same.

43:59

You can't change the gain, you can't change any

44:00

of the settings, okay?

44:02

So based off of this alone,

44:04

your differential would be infarcted, left testicle, um,

44:07

torsion or some other reason hematoma can look

44:10

heterogeneous or mass.

44:11

Those are the three things I'm

44:12

gonna consider on the left side.

44:13

Presumably that's the side that is painful

44:15

that you also need to know is which side is abnormal.

44:18

So how do you decide between those three

44:20

things, Doppler, right?

44:22

So that's gonna be our next thing here is color doppler.

44:24

And so with this we can see the right has color doppler

44:27

but so does the left.

44:28

And our tech even wrote that they did not change the color

44:31

here, they did not crank it up, trying to find a little bit

44:34

of flow on this side.

44:35

So this is telling us now we can exclude an infarcted testic

44:39

all this thing is not tors

44:40

because there's clearly blood flow in it.

44:42

And we can also exclude hematoma

44:43

because that's a lot of blood flow.

44:45

So I would argue at this point you could just almost stop

44:48

but that this is going to have to be a mass

44:51

or it's an oras, right?

44:52

That's what we are considering at this point.

44:55

Um, and at this point though it was called could be either,

45:00

could be an oras, could not be.

45:02

So things to do in this case when you're not really sure

45:04

what you're seeing, my tips are that you need

45:08

to switch probes

45:09

because if it is a mass,

45:10

you will almost always find a rind of normal tissue.

45:14

So in this case the sonographer switched probes

45:16

and sort of backed out a little bit.

45:18

And you can see way up here,

45:19

smooshed up here is normal testicular tissue.

45:22

It will almost always be there when it is a mass.

45:26

You will see that, you'll find it.

45:27

You have to look for it though specifically,

45:29

and again you might have to switch probes to see it.

45:32

You also need to know which side is symptomatic.

45:34

That is certainly helpful because it's gonna

45:35

change what you're thinking about.

45:38

Um, and that buddy view is gonna help you as well.

45:40

Um, if you are thinking about neuritis,

45:43

because this is big heterogeneous

45:44

and it's vascular oris very rarely occurs on its own.

45:47

So you wanna see that epididimitis as well.

45:50

And honestly usually oras is aren't this heterogeneous

45:52

unless they've infarcted.

45:54

So at that point you would see less flow.

45:56

But again, if you're not sure, if you're just,

45:58

you're really just not sure, maybe there is an epididimitis

46:00

going on in the left side as well.

46:01

Just ask for tumor markers.

46:02

They can get them usually fairly quickly within a day or two

46:05

and that's gonna tell you right away, which it is.

46:09

So again, differential for this image

46:12

or for this kind of appearance in general would be an oras.

46:15

So here's an example, different case, uh,

46:17

where the oras is gonna be hypervascular.

46:20

So this case you need to know which

46:21

one is the problem, right?

46:22

Which side is symptomatic and in this case it was the left.

46:26

This clearly has much more vascularity than the right does.

46:28

So you can confidently diagnose neuritis

46:30

and of course you should be looking for the epididimitis

46:32

because usually it goes epi first.

46:34

Then over to the testicle

46:38

you can also think about a hematoma.

46:40

Um, in this case this was uh, a hematoma right here.

46:43

It almost sort of looks like normal testicular tissue,

46:46

but there was nothing going on there.

46:47

It's pretty avascular.

46:49

This is either very minimal residual flow

46:51

or it was just artifact.

46:53

So hematoma should be avascular.

46:55

This one was not particularly heterogeneous

46:57

but they certainly can be.

47:00

And also you certainly do want the trauma history with

47:02

that too, to diagnose with hematoma.

47:04

And then torsion, right?

47:05

This case sort of looks like the case I showed just a few

47:08

clicks ago where you're like, ah, this is a,

47:10

this is clearly a very, very vascular testicle.

47:13

But in this case, the right side was the symptomatic side,

47:16

so they were having right sided pain

47:18

and so that makes this um, either a torsion

47:21

or an infarcted testicle for some other reason.

47:24

So what ended up happening, the reason this looks

47:26

so vascular is probably there was nothing on this side.

47:28

So the sonographer really bumped up their settings to try

47:31

and get any vascularity.

47:33

So this looked hypervascular

47:34

where in reality it was probably normal,

47:36

maybe a little bit increased,

47:37

but this had absolutely nothing

47:39

because this was an infarcted testicle.

47:43

Okay? And so we're heading towards the end.

47:45

So this is ri I think I have two cases left.

47:48

This is just a case here where abnormal bowel loops,

47:50

but you have to look at everything.

47:52

You can see right here there's branching tubular, um, D

47:55

or uh, lucencies right here.

47:57

This is portal venous gas which makes this, um,

48:00

infarcted bowel or most likely infarcted ischemic bowel.

48:04

All right, so this is a patient 30-year-old was recently

48:07

discharged, four days postpartum after delivery

48:11

and returned with right lower quadrant pain.

48:13

And so as you're looking at this,

48:15

I will say the preliminary read was

48:17

that the uterus was enlarged.

48:18

I agree it is, it's at the level of umbilicus.

48:21

And I said, ah, it must be retained products of conception.

48:23

However, the patient was not coming

48:25

in for abnormal bleeding.

48:26

They were not coming in um, with, you know, anything

48:30

concerning for the uterus itself.

48:33

But that's where we focus given the history.

48:35

So this is a good case of where the history sort

48:37

of sways you one way

48:38

and you have to keep an open mind,

48:40

you have to look at everything.

48:41

And this particular case,

48:43

what wasn't noticed was this structure right here,

48:46

which is a little bit enhancing, um, apen deli right here

48:50

and very subtle but definitely real inflammation

48:53

around this tubular structure,

48:55

which if you followed it connected to the cecum

48:57

and didn't connect to

48:58

anything else, this was a blind ending.

48:59

Tubular structure, subtle inflammation, very asymmetric

49:02

to the fat over here, which is much darker.

49:05

So we called her back again, an axial right here.

49:08

There it is right there. So this was an acute appendicitis.

49:11

So she just was unlucky.

49:12

She had given birth four days before.

49:13

She had no problems with her

49:15

uterus except it was a little bit big.

49:16

Um, but she had an acute appendicitis

49:18

and that was operatively confirmed.

49:22

So in a case like this, I just wanna say

49:24

that history is absolutely important.

49:26

We should never ignore history. She's four days postpartum.

49:28

We should of course be looking at the uterus.

49:31

But you have to remember as a radiologist to do

49:33

that systematic search and to follow the inflammation

49:36

because it can lead you to a different diagnosis.

49:39

All right, so this is my last

49:40

case, so I'll go through this one.

49:41

This was a 34-year-old presenting

49:43

with acute onset abdominal pain, nausea, vomiting, diarrhea.

49:47

They actually started with A CTA

49:48

because they had a positive fast scan.

49:51

So someone in the ED had their ultrasound, put it down

49:53

and saw there was blood.

49:54

So 34-year-old acute onset abdominal pain.

49:57

This is the non-con part of the CTA that we did.

50:00

And you can see this definitely blood.

50:01

This is too dense, right? So we've got a lot

50:03

of bleeding in the pelvis.

50:04

They did an arterial phase, they also did a Venus.

50:07

I'm only showing you the Venus.

50:08

And you can see there's this structure right here.

50:10

This is the bleeding site.

50:12

It looked like this in arterial

50:13

and then got a little bit more on the Venus.

50:15

So we found something that is bleeding.

50:18

We have these two al cystic structures back here

50:22

and I'm gonna show you the sagittal image.

50:23

So looking at this right here, we'll say she had um,

50:26

an ultrasound image from two years

50:28

before, um, that showed a normal uterus.

50:33

So the questions I want you to think about this,

50:35

what might this bleeding be coming from?

50:37

She does still have a uterus. She does still have ovaries.

50:39

I'll let you know that. So

50:41

what might this bleeding be coming from

50:44

and what's really the next most important question that

50:47

absolutely has to be asked in a patient like this?

50:50

So this is a 34-year-old female with bleeding in her pelvis.

50:56

So as you sort of think through that,

50:57

I'm gonna tell you the things that I would think about.

50:59

Things that can bleed in a female pelvis

51:01

where you still have a uterus and you still have ovaries.

51:03

This could be endometriosis.

51:05

We have big cystic things on ct. They can bleed.

51:07

This could be end endometriosis,

51:10

it could be a hemorrhagic cyst.

51:12

They can bleed a lot.

51:14

Normally they don't, but they absolutely can.

51:16

But again, in this case we know the bleeding

51:17

is from up here, right?

51:18

It is not from these cystic structures.

51:20

The ovaries are clearly separate.

51:21

So this is not something bleeding from the ovary.

51:24

So I think on the SAG right here, you can sort

51:27

of hallucinate the uterus right here.

51:29

So I think an important question, the question I want you

51:31

to ask in every patient, just

51:33

because they had a CTA doesn't exclude this,

51:37

could she be pregnant?

51:38

Because if the answer is yes, this is an ectopic pregnancy

51:42

until proven otherwise.

51:43

And so in this particular case, um, it's not in the adnexa.

51:47

It's almost sort of anterior to the uterus right here.

51:50

So my question is always with these in a female patient

51:53

who has a uterus and ovaries, could she be pregnant?

51:55

That is the first question. Just

51:57

because you get a CT scan,

51:58

patients do not always know they're pregnant.

52:00

You cannot assume that someone tested a

52:01

beta level at this point.

52:03

So could she be pregnant?

52:04

'cause if she's pregnant, again, ectopic pregnancy,

52:06

otherwise it could be any of the other things

52:08

that we mentioned which are not quite as urgent or emergent.

52:11

So her relevant history was that she had had C-sections.

52:14

So we thought, um, said get the betas.

52:17

The betas were like a thousand, 2000, something like that.

52:20

So we said this is concerning for a C-section,

52:23

ruptured ectopic pregnancy, they went to the OR emergently

52:27

and that is what they found.

52:28

Um, this was the image

52:29

where this purplish structure right here was protruding from

52:33

the uterus and causing the bleeding.

52:35

So again, don't assume a patient not pregnant

52:38

because they're coming to you first on a CT scan.

52:40

Sometimes they get rushed to the CT scan

52:42

before they have a beta

52:43

because they either don't think they're pregnant

52:45

or the betas just aren't back yet

52:46

and they need that CT scan.

52:48

So belly full of blood. Think of hemorrhagic cyst.

52:50

Think of ruptured ectopic, think of endometriosis

52:53

and don't recommend the ultrasound to confirm if

52:55

that beta's positive they need to go to the or.

53:00

Okay. So tips and tricks. Uh, this is just a different case.

53:03

This one was a ruptured ad nexel ectopic.

53:06

So this was in the fallopian tube here.

53:08

Uh, I think the person really thought it could be a dermoid

53:10

'cause there was fat centrally.

53:11

Um, but again, if you don't think

53:13

that they could be pregnant, you will not make the diagnosis

53:15

of a ruptured ectopic pregnancy.

53:17

It will be a delayed diagnosis.

53:19

So I just encourage you to always think about

53:21

that in appropriate case, could the patient be pregnant?

53:24

Yes or no? Ask for beta. Look for beta.

53:26

If it's not, then go down a different,

53:28

uh, differential there.

53:30

So with that, um, thank you again for coming.

53:33

Thanks for your attention

53:34

and if there are any questions in the chat,

53:36

I am happy to take them now.

53:38

Thank you so much Dr.

53:39

McGillan for that awesome case review.

53:41

Yes, we will now open the floor for some questions.

53:46

If you would like Dr.

53:47

McGill to answer a question, please go ahead

53:49

and place that into the q and a feature.

53:54

Dr. McGill, I'm not sure if you can pop open

53:56

that q and a box.

53:57

There's a couple in there already.

53:59

Okay, let's see. I'm happy to read it

54:00

to you too if you can't find it.

54:03

Yeah, you can go ahead and read it

54:04

while I, while I search for it

54:06

For sure. Yeah. What

54:07

is the best imaging modality when accessing

54:09

abdominal assessing, excuse me, abdominal emergencies?

54:13

That's a great question and I think it,

54:15

it's like everything in radiology and medicine, right?

54:18

It's gonna depend on what you're looking for

54:20

and I think it have to weigh, um,

54:23

if something can answer your question, um,

54:26

what's the best answer to it, the patient scenario,

54:29

can they hold still for something that you might wanna get?

54:31

Um, and of course, um, is it gonna prompt something else?

54:35

You know, so if you're looking for a small bowel

54:37

obstruction, you might say, let's start with an x-ray.

54:40

But if you don't know why they're gonna have

54:42

that small bowel obstruction, the

54:43

CT would've been more useful.

54:44

So I think it really always depends on the end goal of it

54:48

and a lot of times we might not be the best person

54:50

to know all that kind of information,

54:52

but it is really helpful when you know, someone calls down

54:54

and gives you the clinical scenario

54:57

and you can sort of talk through

54:58

what you think the patient can tolerate,

55:00

what the real most major question is

55:02

and kind of go from there.

55:04

So no, there's no real good answer to that one.

55:06

It's gonna be very variable depending on the

55:08

patient and how we're presenting.

55:11

Thank you. I I can

55:12

see them now so I can, okay, perfect.

55:14

Okay. Um, is there a good way to differentiate benign

55:17

and malignant biliary strictures?

55:19

There can be, um, if you see an abrupt shouldering,

55:22

let's see if I can, um, make my pen work real quick.

55:25

So if you see like an abrupt shouldering, oh no,

55:27

I got the wrong one pen.

55:31

No, I'm not gonna be able to do it. Okay.

55:33

If you, if you can see an abrupt sort of shouldering type

55:35

of appearance, that can certainly

55:36

suggest a malignant stricture.

55:38

Um, obviously if you can see a mass, a soft tissue mass,

55:42

that too is going to um, tell you

55:45

that it's more likely a malignant stricture.

55:47

But ultimately we're never gonna be 100% going either which

55:50

way benign or malignant.

55:51

So like even in that case where she'd been er ccpd

55:54

before they knew it wasn't gonna be malignant, um,

55:56

they still test for it

55:58

so it's never gonna be a hundred percent.

55:59

You can really look to see if there are signs of malignancy,

56:02

you know, metastatic disease and then you can be sure, but

56:05

otherwise it's really gonna come down

56:06

to the procedure and the pathology.

56:10

Okay, next question. In your last case,

56:11

could it be scar topic pregnancy?

56:12

That is exactly what it was. Um,

56:14

and again, it's one of those things if you don't think about

56:16

it, you're not gonna make that diagnosis.

56:19

You're just not. And you, it is helpful to have

56:21

that C-section history, but we can always raise it

56:23

and be like, hey, did they have a C-section?

56:24

If they're beta positive. So it was a scar ectopic

56:27

pregnancy, the C-section specifically.

56:31

Okay. And duodenitis versus groove pancreatitis?

56:34

Great question. I don't think we can always tell um,

56:37

which it's gonna be necessarily.

56:39

Um, groove pancreatitis, there's some literature out there

56:42

that says it's going to be due to an aberrant um, duct

56:46

or the minor papilla, it's the um,

56:49

I'm losing the words right now, but it's gonna be a result

56:51

of the minor papilla causing the groove pancreatitis.

56:53

But on a CT scan you can't necessarily know that.

56:56

Um, lipase might be helpful

56:58

but it's probably gonna be a little bit elevated in both.

57:01

So it may not be able to help

57:02

and sometimes honestly it's just gonna be a differential.

57:05

If you think the inflammation is more centered

57:06

between the duodenum and

57:07

pancreas, you're gonna go with groove.

57:09

If it's completely around the duodenum, you're gonna go

57:11

with duodenitis and sometimes you just might be wrong.

57:14

So just letting you know that. Okay, next one.

57:19

How do we differentiate between a diverticulitis

57:21

and epi appendicitis?

57:22

Oh, I love that question. That is fantastic.

57:25

So one thing you have to always do is see

57:27

what the inflammation is centered around.

57:29

It's sort of like the claw sign I showed you

57:31

with the renal cell carcinoma,

57:32

except we're gonna use inflammation.

57:34

What is the inflammation centered around?

57:36

So in this case, if it's a diverticulitis,

57:38

you're gonna see a little thickened outpouching

57:40

and the inflammation's gonna be like a little sort

57:42

of semicircle around it.

57:44

Whereas an epi appendicitis, the center of

57:46

that will not be the soft tissue of a diverticulitis.

57:49

It'll be a little fat focus.

57:51

So it'll be fat surrounded by the inflammation

57:54

and that is how yout,

57:55

and again, sometimes you're gonna see it better on the

57:57

coronal and you might not notice it on the axial.

58:00

But again, it's one of those things, if you don't look for

58:02

that diverticulum, you won't see that, oh wait, this is fat,

58:05

this is a actually an IC appendicitis different treatment.

58:08

Right. Great question.

58:11

Okay, please explain how to confirm pneumatosis coli.

58:14

So sometimes it's really hard.

58:16

Um, I'll throw that out there.

58:17

Sometimes you can't tell,

58:18

but for the most part I find using liver,

58:21

or sorry lung windows to be the best thing you're gonna see

58:24

um, a splitting of the different layers of the bowel,

58:27

which you normally cannot see on CT scan,

58:30

but you might not notice it

58:31

unless you specifically specifically put on lung windows.

58:35

Um, sometimes stool will trap things in a way

58:38

that really almost look like pneumatosis coli.

58:40

So I'll look for air that's in a weird spot.

58:43

Um, is there stool there to account

58:45

for why it's trapped in a weird spot?

58:46

But lung windows are gonna be your best.

58:48

And again, sometimes you can't tell

58:49

and you have to give a differential,

58:50

but you can look for other, again, secondary signs.

58:53

Is there inflammation there?

58:54

Is there abnormal colonic wall thickening

58:55

or small bowel wall thickening?

58:57

Is there clot in the SMA?

58:59

And that's actually what's causing the

59:00

pneumatosis because it's ischemic.

59:02

So looking for those secondary things can absolutely help

59:05

you decide too if you think you're over calling it

59:07

or if you think you're actually seeing it.

59:10

Okay, next one. Cystic artery Doppler

59:12

evaluation for acute coli.

59:14

Is that part of your standard imaging protocol?

59:16

It is not at this point.

59:17

We've discussed it and honestly the, this article,

59:20

I forget exactly when it came out, but it's pretty recent.

59:23

Um, so it's something we're gonna start looking at.

59:25

If we should add that in,

59:27

I think there's gonna be training involved with it

59:29

because the sonographers may not be used

59:31

to finding the cystic artery specifically to do it.

59:35

Um, so there's gonna be some training involved

59:37

and we have to decide that we're gonna do it.

59:39

But I think that we're gonna head there.

59:40

I'm gonna push there because I was just so impressed

59:42

with the, the tensile fundus sign and how amazing that was.

59:46

I always think more information is better,

59:48

so it's not at this point,

59:49

but I think we're gonna head that way.

59:53

Okay. Uh, any specific er abdominal CT protocol?

59:56

For general cases, we just use a portal venous phase

60:00

that is our definite workhorse for abdominal cts.

60:03

Um, we use that actually very similarly for our traumas.

60:07

Um, we don't obviously use it for CTAs

60:09

that's gonna be different, but

60:10

generally a portal venous phase.

60:12

Um, we've actually started to

60:15

tell our ED docs if they are not sure when they're looking

60:17

for like a renal stone or something else, you know,

60:20

like appendicitis or so something inflammation

60:23

or a pilo, something that you really would do better

60:25

with IV contrast.

60:26

We've even encouraged them

60:27

to pick the IV contrast over a non-con when they're

60:31

considering something else besides renal stone

60:33

because you're still gonna find the obstructing stone, uh,

60:36

if you give contrast as long as their renal function is okay

60:39

and it gives you a better chance at finding some other

60:41

subtle inflammatory process.

60:42

So portal venous phases are standard workhorse CT protocol.

60:47

Okay. How common is acute MRI available

60:49

in young female patients?

60:51

Is it that common in the uk?

60:53

Um, where I am, it's gonna be different in every country

60:56

and I think honestly every hospital

60:58

I'm at an academic center.

61:00

Um, we do a lot of acute MRI, uh, we probably do too much

61:04

of it, but we do a lot of it, so it's pretty available.

61:07

We have a pediatric hospital too, so we're very used

61:10

to scanning them for appendicitis.

61:12

Um, pregnant patients get scanned

61:14

for appendicitis that way as well.

61:15

So we honestly use it probably

61:18

more frequently than most people do.

61:20

All right. And I know we're over time, but I'll try

61:23

and answer these if you're still on,

61:25

but how can we differentiate between p

61:27

nephron and renal mass?

61:28

Great question. Um, pi nephron is sort of like

61:31

that focal pyelonephritis

61:33

where it's really looks like a mass.

61:35

Sometimes you can't just by imaging alone,

61:37

you can certainly, um, correlate

61:39

with the urinary analysis p nephron, it's gonna be positive

61:42

or renal mass, it's probably not.

61:44

But in those kind of cases I will usually

61:46

just ask for a follow-up.

61:47

Usually the patient population's different

61:49

too, but not always.

61:50

So I ask for a follow-up and honestly, usually within a week

61:53

or two of being treated with antibiotics, um,

61:56

that mass like area will start to scar and shrink down

61:59

and you'll know it's not a renal mass.

62:01

So in those cases I just ask for a follow-up, um,

62:04

within a few weeks and you'll be able to tell

62:06

for sure which one it was.

62:09

Um, diagnosing, pyelonephritis using

62:10

ultrasound, I personally hate it.

62:12

Um, I think it's one of those things where if you can see it

62:14

and it's positive, great,

62:17

but most of the time you cannot see it.

62:19

Um, my, our patient population here tends

62:21

to be a little bit larger, so we're not gonna get the

62:24

sensitivity to look for subtle, you know,

62:26

different changes in the parenchyma

62:28

echogenicity that you might see.

62:29

We're just not gonna see it if you use it.

62:32

Um, in a patient population like mine, it's really to look

62:35

for a renal abscess.

62:36

In that case it's already clinically diagnosed

62:38

or some other way, we're just looking for the abscess.

62:41

Um, how would you suggest abdomen in a traumatic injury?

62:45

I think it depends. For the most part we still do like a

62:48

portal venous type phase of imaging.

62:50

You could do a split bolus to try and get the artery

62:52

or the aorta be really lit up.

62:54

Um, but our trauma people often will be at the scanner

62:57

and they decide too if they want a delayed phase,

62:59

if they see any bleeding, anything bleeding

63:01

or they're not sure, they just get a delayed phase.

63:03

As far as I know, delayed phases aren't really out there in

63:06

the literature exactly how delayed you should be,

63:08

whether it's, you know, two

63:09

minutes, three minutes, five minutes.

63:10

So I think usually somewhere between three

63:11

and five minute delay is reasonable to look

63:14

for active extravasation, um, if something is bleeding,

63:17

if you see a laceration.

63:19

Okay. And last question I have here.

63:21

Role of imaging and ascending cholangitis,

63:23

ultrasound versus ct.

63:25

I think the, uh, recommendation is to start with ultrasound.

63:28

Um, I don't find ultrasound to often uh, be able

63:32

to tell you yes or no with it,

63:34

but that is the way the place you're supposed to start.

63:36

It's one of those where if it's positive,

63:38

if you see biliary dilation, you see, you know stuff, crud,

63:41

echogenic stuff in the bile ducts, then you've diagnosed it,

63:44

but it doesn't exclude it.

63:46

Um, so it's one of those where if you see it great,

63:47

you've diagnosed it, you're correct,

63:50

but you haven't excluded it if it's negative.

63:52

So you might need a CT also, not the best one's really.

63:55

MRI's gonna be your best imaging of it,

63:58

but that's usually not gonna be

63:59

available in the acute setting.

64:00

So if you're looking for a ct, you're looking

64:02

for the biliary dilation, that abnormal enhancement.

64:05

Um, so again, start with ultrasound usually,

64:07

but oftentimes just know it's probably gonna be negative

64:10

and you're gonna need to move on

64:11

to something else if they're still concerned about that.

64:13

So sorry for talking so quickly,

64:15

but I wanted to get through all of those as best as I could.

64:18

Thanks again for having me and uh, thanks for participating.

64:22

Thank you so much for the, the great case review

64:24

and then answering all those questions.

64:25

It was, it was awesome.

64:26

Thank you so much for being here, Dr.

64:28

McGillen.

64:29

Take care. Yeah,

64:31

and thank you for everyone else

64:32

for participating in our noon conference

64:33

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64:35

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64:38

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64:40

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64:43

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64:45

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64:48

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64:51

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64:53

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64:55

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64:56

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64:59

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