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10 month old girl with diarrhea and abdominal pain.

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Let me,

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I'm going to show you two sets of images here,

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one after the other,

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so in the right lower quadrant. So,

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because the patient presented with abdominal pain and fever and there was

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suspicion of appendicitis, um,

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we started with the right lower quadrant which showed thick bowel loops.

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That's the left lower quadrant with thickened bowel loops.

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There is fluid in the bowel.

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Mid abdominal showed the same thing, mild bowel wall thickening.

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And as we look at the liver, it looks very heterogeneous,

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very heterogeneous with areas of hypo and hyper ity.

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On color doppler, there was normal quarter flow,

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but the liver showed normal vascularity did not show any abnormal vascularity.

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That's the kidney, that's the spleen.

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Spleen was not enlarged

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and we intervened. We thought there is something wrong.

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And we repeated the scan after the patient got admitted and after

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six hours there was magic. The s liver looked absolutely normal.

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So within six hours from a severe

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heterogeneity of the liver, this liver now looks normal. Again.

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The vascularity on colored Doppler examination was normal.

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There was no mass or mass effect. Gall bladder is normal.

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All the rest of the organs were normal. No free fluid. The bladder was normal.

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Everything was normal. So let's bring up the poll question.

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So what could it be? It could be, could it be infiltrative tumor,

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could it be ous gas?

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Could it be artifact or could be storage disorder?

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Uh, unfortunately that's not ous air.

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There was bowel wall thickening, but we never saw air in the bowel wall.

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There was no intramural air. This was from dehydration.

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The patient had diarrhea, had gastroenteritis,

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very slow flow within the hepatic vasculature from rule

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formation dehydration that led to that artifact. Typically,

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we see that artifact in the large veins with obstructive changes,

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especially in patients who have D V T et cetera will have slow flow in the large

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veins. The same concept we need to apply when we look at the organ system on

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ultrasound, especially on grayscale images. If there is very slow flow,

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you see that those alternate bands you saw on the initial ultrasound.

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So those hypoechoic areas and hyper alternate areas.

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So hyper echoic areas where the, uh, blood cells which

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Were, are traveling very slow within the hepatic vasculature.

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After the patient got rehydrated IV infusion was done for six hours

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and we imaged the liver again, it was normal.

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So Porto's gas, um,

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typically is more hyper echoic and will show discreet areas of

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hyper ity with post caustic dirty shadowing. I'm,

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I'm to say dirty shadowing from the air bubbles. And you'll also see,

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uh, air, intramural air when we, when you look at the bowel.

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So very tricky case. Um, the patient was, mine had, uh,

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mild elevation of LFTs, uh, next day, but did extremely well.

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So that's a rule formation. RBCs,

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they clumped together and they traveled together in the, uh, in the, uh,

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vessels very slowly leading to that kind of artifact. So, um,

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it was fixed after rehydrating the kid.