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Hello and welcome to noon conferences hosted by MRI Online.

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In response to the changes happening around the

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world right now and the shutting down of in-person

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events, we have decided to provide free daily

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noon conferences to all radiologists worldwide.

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Today we are joined by Dr. Deitte.

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Dr. Deitte is active with teaching at all levels, medical

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students, residents, fellows, and practicing physicians.

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She is a nationally recognized speaker and

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has given more than 130 invited presentations.

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Her specialty areas are body imaging and ultrasound.

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A reminder that there will be a Q&A session

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at the end of this lecture, so please use the

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Q&A feature to ask your questions and we will

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get to as many as we can before our time is up.

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That being said, thank you all for joining us today.

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Dr. Deitte, I'll let you take it from here.

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All right.

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Um, thank you so much for that introduction.

0:58

My name is Lori Deitte.

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I'm the Vice Chair of Education at Vanderbilt Radiology.

1:02

And today we're going to talk about

1:03

ultrasound can't-miss diagnoses.

1:07

I'd like to thank

1:08

Dr. Jani Collins and MRI Online for this opportunity.

1:14

So I don't have any disclosures.

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And I have two learning objectives.

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The first one is to describe the sonographic

1:22

features of can't-miss diagnoses.

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And the second is to apply this information to a

1:29

specific clinical presentation to make the diagnosis.

1:34

So let's get started with can't-miss diagnoses.

1:37

Categories we're going to talk about today are

1:40

gynecologic, sclerotal, transplant, and other

1:47

gas-forming infections, and acute hemorrhage.

1:55

In general, my approach to ultrasound diagnosis

1:59

and management is determining, A, is this an

2:04

urgent surgical or procedural management needed?

2:08

Do we need to be communicating

2:09

these, um, results really urgently?

2:12

Or is it non-surgical management?

2:17

Or is follow-up needed?

2:20

Or another diagnosis?

2:23

So I'd like you to put yourself in this mindset.

2:26

You are on call.

2:28

A woman presents with acute pelvic pain.

2:32

An urgent ultrasound is requested.

2:35

What's next?

2:36

What’s something, what are some things that

2:38

you’d really like to know about the patient?

2:41

Laboratory data?

2:43

Absolutely.

2:44

If it's a patient of childbearing age, the one thing I

2:46

absolutely want to know is the result of the pregnancy test.

2:50

And then other clinical information.

2:54

So let's start with our patient.

2:56

Patient comes in with pelvic pain.

2:58

This is her transvaginal ultrasound.

3:01

You can see the uterus.

3:06

We do see this echogenic area.

3:09

structure in the endometrium.

3:12

And then there's another observation surrounding the uterus.

3:16

So here's the posterior margin of the uterus.

3:19

And then surrounded is all this heterogeneous fluid.

3:23

So I said, one thing I absolutely want to know is a

3:25

pregnancy test result on this, uh, patient.

3:29

And she was in fact positive.

3:33

Interesting that this echogenic

3:34

structure in her endometrium is an IUD.

3:40

And this fluid surrounding her uterus is hemorrhage.

3:45

So we looked a little bit further, um, into the

3:49

fluid in the adnexal region and we saw this, and this

3:55

has a thickened rim, echogenic rim, it's anechoic

3:58

centrally, and has an appearance of a tubal ring sign.

4:05

So we said we were most concerned about a ruptured

4:08

ectopic pregnancy, and she did go to the OR and had a

4:13

ruptured left ectopic, and she in fact did have an IUD.

4:20

So, I have a question for you to think about.

4:24

The most common location of an ectopic pregnancy

4:28

is in the interstitial segment of the tube.

4:31

True or false?

4:36

That's false.

4:39

So, let's look at ectopic pregnancy.

4:41

First of all, risk factors, PID, prior inflammatory

4:45

processes, prior ectopic, and then in vitro fertilization.

4:50

Very important because these patients can

4:52

have multiple pregnancies and sometimes be at

4:57

increased risk for a heterotopic pregnancy.

5:00

So, a pregnancy that's both in the uterus and a separate

5:03

pregnancy that's ectopic outside of the uterus.

5:07

75–80% of ectopic pregnancies are

5:11

in the ampullary segment of the tube.

5:15

A smaller proportion, 2–5%,

5:17

are in the interstitial segment.

5:20

Um, very important diagnosis to make, though,

5:23

because the presentation can be a little bit

5:26

later, and they can have substantial bleeding.

5:30

And we already mentioned the tubal ring sign is very

5:33

helpful for, um, the diagnosis of ectopic pregnancy.

5:37

But sometimes all that you get is a complex mass.

5:39

You don't see a pregnancy in the uterus.

5:41

You have this complex mass in the adnexa.

5:44

You think it's probably hemorrhage, and then you still,

5:47

you know, still likely to be an ectopic pregnancy.

5:52

This is another example of a tubal ring sign.

5:55

And I'm going to outline the ring here.

5:57

It's a thickened rim.

5:59

It's, it's centrally anechoic.

6:01

This one did not have a yolk sac in it yet.

6:03

And then next to it, but separate

6:05

from it, is the left ovary.

6:08

This is a different patient.

6:13

There's our tubal ring.

6:17

This is another patient that had an ectopic pregnancy.

6:20

So it's a transvaginal ultrasound.

6:23

Uterus here.

6:24

We did not see a sac in the uterus.

6:27

Left ovary outlined here.

6:31

And a corpus luteum in the left ovary.

6:34

And then between the ovary and

6:36

the uterus is this additional sac.

6:39

This is the gestational sac.

6:41

And you can actually see a little yolk sac in this.

6:44

So, this was a tubal ectopic pregnancy.

6:53

I mentioned that it's very important to make

6:56

the diagnosis of an interstitial pregnancy.

6:59

And this is an example of a patient that

7:02

we had that had an interstitial pregnancy.

7:05

So, here is again a transvaginal ultrasound,

7:08

and we can see the endometrium here.

7:13

And then we could actually see a little line.

7:15

It doesn't show up well on here, but it

7:17

extended from the endometrium to this sac,

7:21

which is, um, eccentrically positioned and

7:25

had very little, if any, myometrium around it.

7:29

This does have a fetal pole and a yolk

7:31

sac in it, and this was a confirmed, um,

7:34

operatively confirmed interstitial pregnancy.

7:42

So, this patient was referred to us as,

7:46

uh, concerned for interstitial ectopic.

7:51

So, is this an interstitial ectopic pregnancy?

7:55

Okay, again, a transvaginal ultrasound.

7:59

You can see the endometrium.

8:02

I'm outlining it.

8:06

And you can see that it goes eccentrically a

8:08

little bit off to the left as well as to the right.

8:11

And then there is this yolk sac

8:13

that's eccentric in position.

8:15

It's a true gestational sac.

8:17

I meant to say gestational sac, and it has a yolk sac in it.

8:22

So it's a true gestational sac.

8:24

It's eccentrically located.

8:29

We did some more imaging.

8:32

This is the sac.

8:33

It is up to the right.

8:38

And what would you do next?

8:40

What could help with determining, this is a really

8:42

important determination, whether this is actually an

8:45

intrauterine pregnancy or is an ectopic interstitial.

8:48

We also measured the myometrium around this

8:51

and we got greater than five millimeters.

8:55

So our thought process was that this is not an

8:57

interstitial pregnancy, and we did a 3D image, and I

9:02

think this nicely shows, um, so this is a coronal image,

9:06

and we can see, um, the left, and then you see this

9:10

little myometrium sort of indenting the endometrium,

9:14

and then going off to the right, and this is our sac.

9:17

This turned out, um, we can see endometrium

9:20

going all the way around it, and this turned

9:23

out to be an eccentric angular, um, pregnancy.

9:27

We, uh, followed this patient and

9:29

this is an image at seven months.

9:30

You can, um, see this third trimester pregnancy.

9:35

So an important, really important decision making

9:38

process because if it's an interstitial pregnancy,

9:41

it's an ectopic pregnancy, as opposed to this pregnancy,

9:45

which went on, um, through the third trimester.

9:53

Another, um, consideration when we're thinking about ectopic

9:57

pregnancies is in patients with Müllerian duct anomalies.

10:02

And this patient had prior imaging that showed a

10:07

normal right uterine horn, but a rudimentary left

10:11

uterine horn that was actually non-communicating.

10:16

She had a positive pregnancy

10:17

test and came to us for imaging.

10:20

And this is the normal right horn.

10:24

And this is the non-communicating left horn,

10:28

which unfortunately is the horn that has the pregnancy in it.

10:33

So this horn cannot maintain a pregnancy.

10:37

Um, this, we can see here the gestational sac.

10:40

We can see the yolk sac.

10:41

So this is basically treated like an ectopic pregnancy.

10:45

There is a little bit of free fluid here as well.

10:52

Okay.

10:52

We're going to move on to a different topic.

10:54

So we now have our 29-year-old

10:57

who comes in with pelvic pain.

11:00

And we're doing comparative images of the ovaries

11:03

here, transvag, so here's the right ovary.

11:07

It's nice and normal size, and it's

11:09

about 3 by 2 centimeters on this image.

11:12

This is the left ovary.

11:16

Markedly enlarged, measuring 8.7 by 4.5 centimeters.

11:22

Abnormal morphology.

11:24

Heterogeneous centrally, peripheral small follicles.

11:29

Okay, so already based off of this grayscale imaging,

11:33

your number one diagnosis is going to be a torsion.

11:37

Ovarian torsion.

11:39

We did go on to color Doppler imaging.

11:41

Um, this, uh, this is the right ovary with normal flow.

11:45

This is the left ovary.

11:47

It has a data flow in it.

11:49

Um, definitely, uh, markedly abnormal,

11:51

hardly any flow at all in it.

11:53

So this is a pretty easy diagnosis for ovarian torsion.

11:58

So the most consistent finding with

12:01

ovarian torsion is an enlarged ovary.

12:04

Very, very important.

12:06

Sometimes there's also an underlying

12:07

mass, but an enlarged ovary.

12:10

So grayscale images are very important here.

12:13

You can see multiple peripheral follicles

12:15

like we, like I just showed you.

12:18

And the Doppler findings are variable, and so that

12:22

sometimes makes it a little bit more challenging.

12:24

But there can still be residual flow in a torsed ovary.

12:29

On CT, um, you will sometimes, you will

12:31

see hemorrhage into the ovary or the tube.

12:34

And on occasion, you can actually see the twisted pedicle.

12:37

I have seen that before.

12:42

This is a patient who came in, um, she had a prior

12:46

right oophorectomy for torsion, and then a few months

12:51

later she came in with excruciating acute onset

12:56

of pelvic pain, which, um, she described as being

13:00

almost identical to when she had the prior torsion.

13:03

Now she's fairly young and now at

13:05

this point she only has one ovary.

13:07

This is her left ovary.

13:10

It's enlarged.

13:11

It was about 6.6 by 4.0 centimeters.

13:15

It has a little bit of free fluid around it.

13:18

And then it had a couple cystic structures.

13:21

This looks like a hemorrhagic cyst.

13:23

And then another cyst in it.

13:27

Again, we were already, we were already worried

13:29

because she's had a prior history of torsion.

13:32

She's at increased risk and she is telling us

13:35

that her pain is just like when she had torsion.

13:39

So we went ahead and did Doppler imaging.

13:42

We did demonstrate some arterial flow in this

13:45

ovary, and here's our tracing, and also venous flow.

13:49

It didn't have a lot of flow in it, but I also

13:52

didn't have another ovary to compare with.

13:55

With her story, and she was also really tender when we

13:58

were scanning her, and I often like to go in and be there

14:02

when the patients are, or scan, when the patient, uh,

14:05

when we're scanning, and it helps me get a better feel

14:08

for how much pain they're actually, um, experiencing.

14:14

So we ended up saying that we were

14:16

very concerned about ovarian torsion.

14:18

Yes, there was still some residual flow, but we

14:20

were very concerned, and she did in fact, in, um,

14:23

the OR, she had ovarian torsion and fortunately

14:26

they were able to salvage her left ovary.

14:28

So that was a really good outcome.

14:33

Another patient.

14:36

Right ovary, this one actually has no flow in it.

14:39

And for comparison, this is the size of the

14:41

left ovary, which has some flow.

14:43

So again, markedly enlarged right ovary.

14:47

Another image of it, this is

14:48

absolutely classic for ovarian torsion.

14:51

Again, you can see heterogeneous

14:54

parenchyma, a couple little, um, peripheral

14:55

follicles, and a markedly enlarged ovary.

14:58

That's 6 by 3.6 centimeters.

15:02

That was right ovarian torsion.

15:07

And this is a patient, um, that was pregnant,

15:11

and she came in with right-sided pain.

15:13

Again, acute, you know, acute onset,

15:17

kind of relentless pain, very severe, and this

15:20

is what her right adnexa looked like.

15:23

It was enlarged, heterogeneous.

15:25

We did think that there was an underlying mass.

15:28

Um, there's, it's, there's increased echogenicity here,

15:31

an area that's hyperechoic, and then there were cystic

15:35

changes, so we thought she had an underlying teratoma, and,

15:39

uh, we also did not see flow in this, and, uh, so, so our

15:44

diagnosis was ovarian torsion due to an underlying teratoma.

15:50

Which is what, uh, she did have when she went to the OR.

15:57

Okay, we're going to move to a different category.

16:00

This is a, uh, 27-year-old with pelvic pain.

16:05

We're getting a transvaginal image.

16:07

We can see part of the uterus here.

16:10

And then we see this very complex

16:13

fluid posterior to the uterus.

16:16

So complex fluid, I'll show you another image.

16:22

Very complex, septated fluid, looks kind of

16:26

loculated in parts, has low-grade echoes in it.

16:31

You'd want to know more about the patient,

16:33

like, um, what is her white count?

16:35

Has she had fevers?

16:37

Has she had any history of pelvic inflammatory disease?

16:44

And she also then got the CT,

16:46

which shows a large, rim-enhancing, uh, fluid

16:50

collection in the, um, posterior pelvis.

16:53

Here's the uterus.

16:55

Which is consistent with an abscess.

16:59

So she had pelvic inflammatory disease with an abscess.

17:06

I'll show you one more patient with a similar diagnosis.

17:09

So this is a patient with pelvic pain.

17:12

And she just, she came in and this is what her adnexa

17:16

looked like, heterogeneous, complex collection.

17:20

A few, we could identify a little part of

17:22

the ovary, a few follicles, heterogeneous

17:25

fluid again, um, pus surrounding this.

17:31

And this is another image from her.

17:33

So a huge, um, complex septated abscess.

17:39

She had a tubo-ovarian abscess.

17:45

Okay, next we're going to move to our next

17:49

category, which is scrotal ultrasound.

17:53

I wanted to go over some key images when you're,

17:56

um, reviewing scrotal ultrasound images, or

17:59

if you're actually the person acquiring them.

18:04

So, key images.

18:05

Absolutely, you have to have side

18:06

by side grayscale, the testes.

18:08

Um, we, This is how we compare echogenicity. Is one

18:12

testicle more hypoechoic relative to the other?

18:16

Another nice thing that you can actually see

18:18

on here is, this is a nice look at the tunica.

18:23

And then we do the same thing with color Doppler,

18:25

side by side, very important, especially

18:28

for when we're looking for testicular torsion.

18:33

Often, um, a testicle that's torsed will have no flow in it,

18:37

but sometimes it still has a little bit of residual flow.

18:40

And, uh, the color Doppler images, though, will show

18:44

markedly decreased Doppler flow on the affected side.

18:51

And spectral Doppler imaging is important.

18:53

We're sampling from this gate, the artery,

18:56

and this is a nice normal arterial tracing.

18:59

The important thing here is to make sure that your tracing

19:01

is coming from the testicular parenchyma and that it's

19:05

not coming from the margin or outside of the testicle.

19:08

Okay, it has to be coming from within the parenchyma.

19:13

And then the entire epididymis is important to image.

19:16

Epididymal head, it's a little bit more

19:18

echogenic than the rest of the epididymis.

19:20

And then body and tail.

19:22

Why is that important?

19:24

Because patients can get focal epididymitis,

19:28

and if that happens, it typically starts in the tail.

19:32

So we do a full view of, with color Doppler imaging too.

19:36

This is normal.

19:37

This is a normal one.

19:40

Okay, and then the surrounding soft tissues.

19:43

It's kind of like everything else,

19:45

but definitely important to look at the scrotal wall.

19:47

In this case, we have gas in the scrotal

19:50

wall with this is a normal testicle.

19:52

This patient had necrotizing

19:54

fasciitis, um, spermatic cord region.

19:57

And surrounding, um, structures.

19:59

I've even, um, on scrotal ultrasound, uh, looked down at

20:03

the perineum because I've had, I had a patient once that

20:05

had a perineal abscess that wasn't very, um, we really

20:09

couldn't see it well from on top, but as we scanned, um,

20:12

more posteriorly along the perineum, we saw the abscess.

20:18

So, this is a 19-year-old with acute scrotal pain.

20:22

Our grayscale images, I can just say it looks pretty good.

20:26

Pretty similar between the two sides.

20:28

You might say, hmm, is that scrotal

20:30

wall maybe a little bit more thickened?

20:33

Maybe.

20:34

Let's go to our Doppler.

20:36

Okay, so absolutely, this is again an easy

20:39

diagnosis because there is great flow in the right

20:42

testicle and there's no flow in the left testicle.

20:45

So, left testicular torsion, also shown on

20:50

power Doppler images, no flow in the testicle.

20:59

My question for you is four hours lapsed

21:04

between the onset of pain and when the patient

21:08

got to the OR and had the testicle detorsed.

21:13

The salvage rate is 80 to 100.

21:17

70, 50, or 20, four hours.

21:23

Fortunately, it's 80 to 100.

21:25

Four hours is actually really, um, pretty, uh,

21:28

that's pretty quick to get somebody to the OR.

21:30

If you think about it, the, the clock

21:32

starts ticking when their pain starts.

21:35

So basically, they're at home, two in the morning, get,

21:38

they wake up, they have acute pain, you know, they have

21:41

to get to the hospital, get dressed, get to the hospital,

21:44

they have to be checked in, and somebody has to see them.

21:47

They have to get their ultrasound, and then the results have

21:49

to be communicated, and then they have to get to the OR.

21:52

So four hours is pretty quick for all of

21:54

that to happen, but that would be ideal.

21:57

So, testicular torsion, salvage rate.

22:00

80 to 100 percent if within six hours.

22:03

So that's really our goal.

22:04

And we play a vital role as radiologists.

22:07

We have to, we really need to expedite

22:10

this, um, making the diagnosis.

22:11

So these patients have to be

22:12

prioritized to get their ultrasound.

22:14

And then it's up to us to communicate these results quickly.

22:19

When we go to 70, um, at six to 12 hours, it's 70%.

22:23

And then if it gets greater than

22:24

12 hours, it's really low salvage rate, 20%.

22:28

Our goal is to get to the patient, to the OR.

22:33

Another patient, 20-year-old with pain, right

22:37

testicular torsion, no flow again in this testicle.

22:40

And, and flow, and we know we have our gain turned

22:44

up high because we can see all of this in between the

22:47

testicles, so it's up high and there's still no flow here.

22:50

And nice flow on the left.

22:54

Um, this is a pediatric patient,

22:56

um, with right testicular torsion.

22:58

So what are we looking at?

22:59

Well, here's the left testicle that has nice flow in it.

23:04

And here's the right testicle.

23:06

There's no flow.

23:07

This is powered up.

23:08

There's no flow in this testicle.

23:11

And one thing, another observation on here is

23:14

all this soft tissue adjacent to the testicle.

23:16

This was an enlarged epididymis.

23:19

And so it's important to recognize that the

23:22

epididymis can also enlarge with testicular torsion.

23:26

Because when we think about the differential for

23:28

testicular torsion in, say, a teenage boy, it's, um,

23:34

you know, it's torsion, or could it be epididymitis?

23:38

Both can give an enlarged epididymis.

23:40

However, with torsion, there will be no flow in the

23:43

epididymis, as in this case, whereas with epididymitis,

23:47

there will be markedly increased color Doppler flow.

23:52

This is another, uh, patient that we had,

23:54

7-year-old, left inguinal pain, and the

23:56

working diagnosis clinically was a hernia.

24:00

On ultrasound, there was no hernia seen, but there

24:05

was this bilobed solid mass in the left inguinal

24:11

canal that did not have any color Doppler flow in it.

24:16

And the thought was, uh, is this testicular torsion?

24:20

Is this an undescended testicle?

24:22

And then we're also seeing a slightly enlarged

24:24

epididymis, um, that tors, and that's exactly what it was.

24:31

So, that was an undescended left testicle that had torqued.

24:39

This is a patient that presented with left testicular pain.

24:45

So, right testicle, left testicle,

24:51

spectral Doppler tracings.

24:53

They both have arterial tracings.

24:59

Color Doppler, maybe I can convince you

25:03

that there's more flow on the right.

25:05

Then on the left, on the left we

25:07

just kind of see these couple dots.

25:09

So the side-by-side color Doppler imaging is very important

25:14

because it shows us decreased color Doppler flow on the left

25:18

which is the same side that the patient is symptomatic on.

25:22

Again, side-by-side imaging.

25:25

Decreased flow on the left relative to the right.

25:28

So is it torsion?

25:30

We still have arterial flow.

25:34

So we looked for the spermatic

25:36

cord knot of torsion and we saw it.

25:38

This is actually a nice example of the twisting

25:41

that occurs and, um, confirmed the diagnosis.

25:45

The patient did go to the OR and

25:47

the left testicle was torqued.

25:52

This is a different patient who

25:53

had scrotal pain for three days.

25:55

We know we're way beyond the window

25:57

of being able to salvage the testicle.

25:59

This is his left testicle.

26:01

Um, I'll be showing you a comparison

26:03

imaging of the right, but it is enlarged.

26:05

It is slightly heterogeneous and it has no flow in it.

26:10

These are the side-by-side images.

26:12

So this is the enlarged heterogeneous left testicle

26:15

with no flow that was completely infarcted.

26:20

Moving to a, um, different, um, pathology now.

26:24

This is a 26-year-old with diabetes

26:28

who came in with scrotal swelling.

26:31

Um, ultrasound diagnosis.

26:34

So let's take a look.

26:36

Right testicle.

26:37

Left testicle.

26:39

And then these echogenic shadowing foci around it.

26:45

And I'll say, um, this patient, I remember this

26:47

patient very well because I was, um, actually not

26:50

on ultrasound, but had come in early and, uh, the

26:53

sonographer, um, saw me in the hallway and said,

26:56

Hey, can you come and help me, uh, with this?

26:58

I think I'm really concerned about this patient.

27:00

And so of course I said, yes.

27:04

And this, is gas in the soft tissues.

27:08

So this patient unfortunately, um, had

27:11

necrotizing fasciitis or Fournier's gangrene.

27:14

Um, the history that, uh, he had experienced

27:19

was he had been kind of constipated and thought

27:21

he had developed an anal fissure a couple of

27:23

days prior to his presentation at the hospital.

27:28

My question for you is, are the testicles

27:30

typically involved with this process?

27:32

Yes or no?

27:36

No.

27:36

Usually they're spared.

27:38

So let's talk about Fournier's gangrene.

27:40

This is one of the most important diagnoses you'll make

27:42

with ultrasound is any necrotizing infection is, is a

27:47

very important diagnosis to make and to communicate.

27:50

So underlying etiologies, oftentimes there

27:52

is kind of a minor trauma, sort of a history.

27:56

Um, and the testicles are typically spared.

28:00

Mortality, um, is approximately 21%.

28:05

Combined microorganisms, treatment, broad

28:08

spectrum antibiotics, and unfortunately,

28:10

extensive surgical debridement.

28:12

Um, this particular patient that we diagnosed right away,

28:15

basically went straight to the OR from our ultrasound

28:18

suite, honestly, and still ended up with seven major

28:21

surgeries, um, debridements and reconstructions.

28:25

Another patient.

28:27

Gas in the, um, scrotum wall, left testicle, the one

28:30

that I showed you earlier, had necrotizing fasciitis.

28:35

These are some more images of gas.

28:38

I do want you to be able to take away from,

28:39

um, from our conference today, the appearance

28:42

of gas on ultrasound in soft tissues.

28:47

And this is another patient, 51-year-old with diabetes, and

28:51

a nice example of ring-down artifact of gas in soft tissues.

28:56

And we can also see gas.

28:58

Normal testicle.

29:01

And this is what it looked like on CT.

29:03

It was really very extensive, necrotizing fasciitis.

29:07

The CT is helpful.

29:08

So, um, if somebody, if their primary concern is,

29:12

um, necrotizing fasciitis, CT is a good, is a great

29:16

modality, um, for determining the extent of the

29:19

involvement in, um, how far up it goes and how deep.

29:23

And so my preference is CT, although I have

29:25

made this diagnosis many times on ultrasound.

29:30

One more category, um, patient,

29:33

was at a rowdy fraternity party.

29:35

Uh, apparently there was some trauma involved and, um,

29:38

he woke up, um, a few hours later with scrotal pain.

29:43

And this is his, uh, testicular ultrasound.

29:46

So we can see a testicle that has, um, nice, uh, flow

29:51

internally, and we can follow the tunica, but it's

29:54

abruptly disrupted here and abruptly disrupted here.

29:59

With some of their first tubules

30:01

extruding through the defect.

30:05

and they do not have flow into them.

30:09

Okay, so tunica disruption.

30:12

So testicular rupture is the diagnosis.

30:15

Um, ultrasound is actually very

30:17

important, um, for making this diagnosis.

30:19

And we're looking for tunica disruption.

30:21

Sometimes it's easy, like the one I just showed you,

30:24

where you could actually see the, um, tunica,

30:26

but sometimes you have to look for secondary signs.

30:30

Um, and it's not so easy to see the tunica,

30:34

especially if there's a lot of surrounding blood.

30:36

Um, like testicular contour irregularity would be a clue.

30:40

Altered testicle echogenicity due

30:43

to internal infarction or blood,

30:46

um, hematocle.

30:49

Decreased stapler flow within the testicle or

30:51

within the testicle with extruded portions.

30:54

Why is this important?

30:55

Well, the salvage rate is 90% if,

30:58

within 72 hours, but it goes down.

31:01

So again, it's on us to make this diagnosis.

31:05

This is another patient.

31:06

Um, we can see this is, um, so a ballistic

31:10

injury, um, to the scrotum, and we can see part

31:13

of the tunica here, but then we lose it, and the

31:16

testicle margin, it's very irregular contour.

31:21

We see a little bit of blood adjacent to it.

31:23

Um, and we, uh, we made the diagnosis of testicular

31:28

rupture, uh, this patient who went to the OR and

31:32

had, um, it was ruptured, and they had it repaired.

31:36

And this is, uh, unfortunate, um, fireworks

31:39

mishap, um, to the scrotum, and, uh, a lot of

31:43

gas in the, uh, within the scrotum, and then

31:46

this left testicle is completely disrupted.

31:49

It's very.

31:50

This is the outline of the testicle, very

31:52

irregular, and it's surrounded by all this blood.

31:56

So this was a left testicular rupture.

32:00

Okay.

32:01

Moving on to the next category, um, transplant ultrasound.

32:09

And I'm going to cover only vascular, um, just kind of the

32:12

main vascular, uh, things to look for in liver and kidney.

32:18

So liver transplant ultrasound, the hepatic artery

32:22

is a very, very important part of our evaluation.

32:26

And this is three weeks postoperative on this patient.

32:29

We're sampling from the hepatic artery.

32:31

Our waveform is normal.

32:33

It's, um, there's a nice upstroke and there's.

32:38

Uh, the resistive index is, um, 0.67 here.

32:42

This is normal looking.

32:45

12 weeks later, um, or actually not 12 weeks later,

32:49

but 12 weeks post-op, nine weeks later, the patient

32:53

came in and had this, there's the hepatic artery,

32:59

had this waveform from the hepatic artery.

33:03

Very different than this one nine weeks prior.

33:07

You can see a delayed upstroke.

33:10

So it's a Parvus tardus waveform.

33:12

And the resistive index now is 0.36

33:17

It's abnormally low.

33:19

And it's less than 0.5.

33:22

Which is considered to be low.

33:24

So this waveform makes us very

33:28

concerned about hepatic artery stenosis.

33:31

And that's what we said.

33:33

Hepatic artery stenosis needs further evaluation.

33:35

We recommended a CTA for further assessment.

33:38

The CTA was done and we recommended it urgently.

33:42

And there was a very, very high

33:43

grade stenosis in the hepatic artery.

33:46

It was a short segment, but very high grade.

33:48

And so we were probably sampling somewhere

33:50

around here, distal to the stenosis, okay?

33:53

Because parvus is seen downstream or distal to a stenosis.

34:01

So the patient did undergo, um, angioplasty.

34:05

And this is, um, on the arteriogram, again,

34:09

very short segment, but about a 90% stenosis.

34:12

And after, uh, we repeated an ultrasound.

34:16

This is after the angioplasty.

34:18

And you can see now this hepatic

34:19

artery waveform has again, normalized.

34:22

It looks like it.

34:22

It's got a nice, great upstroke.

34:24

There's no parvus tardus, and

34:25

the resistive index is back to 0.64.

34:29

We are important here because ultrasound is

34:31

used as, um, a screening exam in these patients.

34:35

And so it's really incumbent on us to be familiar

34:39

with waveforms and, um, when we should be concerned

34:43

about hepatic artery stenosis or thrombosis.

34:51

This is a patient who had a re, a recent renal transplant.

34:57

This is an arterial tracing.

34:59

It's a very scary tracing to me.

35:01

Um, so it's a high resistive tracing.

35:06

Um, normally a renal transplant

35:09

artery will have diastolic flow.

35:11

But this one does not.

35:13

It has some, um, forward systolic flow,

35:17

but then it reverses actually in diastole.

35:21

So see, um, seeing this way, the spectral tracing

35:27

from a renal transplant, the number one thing

35:31

that we have to evaluate is the renal vein.

35:33

And look for renal vein thrombosis.

35:35

Because if the renal vein is thrombosed,

35:38

there's still inflow to the transplant kidney.

35:41

It becomes large and edematous.

35:43

And because it's so edematous, the

35:46

artery tracing becomes high resistance.

35:49

And this was in fact, renal vein thrombosis.

35:52

Why is this important when we evaluate, um, when we identify

35:56

it, if we identify it early enough and communicate it right

35:59

away, there's a possibility of still salvaging the kidney.

36:03

Um, unfortunately that wasn't the case with this patient.

36:09

This is a patient who had multiple renal

36:12

transplants and, um, the, with the most

36:15

recent being an intraperitoneal transplant.

36:18

And I have to say I haven't seen, so typically

36:20

a renal transplant is extraperitoneal.

36:23

And typically, the first transplant that's put in is placed

36:26

on the right side, and then if they have a second transplant,

36:28

subsequent transplants are placed on the left side. This can

36:31

vary if there's a concurrent pancreatic transplant

36:34

at the same time. But this was an

36:37

intraperitoneal transplant, and we were looking for flow.

36:41

This is a transperitoneal scan. Here's the renal pelvis, and we

36:47

just couldn’t find much flow in this kidney, and we

36:49

couldn’t find the renal vein. We ended up deciding

36:54

this was the renal vein, which has low-grade echogenicity in it.

37:00

We had some CT imaging on this patient that actually was

37:04

really helpful in figuring out what was going on here.

37:06

This patient had had a CT scan, um, about a month prior.

37:11

And this is their most recent renal transplant.

37:15

You can see an older, non-functioning renal transplant here.

37:18

But on this scan, a month ago, the vein, the

37:24

renal vein was posterior and the renal pelvis was

37:32

in a different position. They had a CT scan, um,

37:36

on the same day as the ultrasound when they presented with acute pain.

37:40

An observation we made comparing the scans

37:44

was that here we saw the renal pelvis

37:49

was anterior before, and now it was posterior.

37:55

And the renal vein was anterior.

37:58

This helped us start to think about a diagnosis

38:01

that I would tell you I had not seen before.

38:04

But this, unfortunately, this transplant kidney is an

38:07

intraperitoneal kidney and it had undergone torsion.

38:10

And, um, so the patient was taken

38:14

to the OR and it had torsed at the pedicle.

38:17

When it was detorsed,

38:19

the vein actually was still patent.

38:22

What we think we saw on the ultrasound image, the low-grade echoes

38:26

and lack of flow, was probably just the beginning

38:29

of a cut-off in flow to the renal

38:32

vein, but it hadn't completely thrombosed yet.

38:39

Okay, we're going to move to another

38:40

category: other gas-forming infections.

38:45

So this is a transplant kidney, and this patient

38:49

came in with an elevated white count and really,

38:52

clinical evidence of a urinary tract infection.

38:55

They have a dilated collecting system.

38:58

It has debris in it.

39:00

And it has these echogenic, dirty shadowing

39:03

areas in it, which turned out to be gas.

39:05

Okay, this is gas in the collecting system.

39:08

And this patient had emphysematous pyelitis.

39:11

Okay.

39:13

So when we say pyelitis, emphysematous pyelitis,

39:15

that means it's only in the collecting system,

39:18

not in the parenchyma, as opposed to this patient.

39:22

This patient has a history of diabetes, and you'll

39:25

see a theme here that many of these patients that

39:27

have necrotizing infections have a history of diabetes.

39:31

But this patient came in with right flank pain.

39:33

And when we did an ultrasound in the right

39:36

renal fossa region, this is all we could see.

39:40

It's echogenic, shadowing, kind of, it had sort of

39:44

a bowel-like appearance, but we had prior imaging

39:48

that had previously shown a normal right kidney.

39:53

So what are we most concerned about here?

39:56

And what might help us figure out what's going on?

40:00

Well, we were worried that this

40:02

was gas, and it's so easy to see on CT.

40:05

So I would say if you ever have a question on

40:07

ultrasound, you can just do a non-contrast CT

40:09

and establish a diagnosis of the presence of gas.

40:13

So here's the right kidney.

40:14

It has gas in the collecting system, the

40:16

parenchyma, and even around the kidney.

40:20

This is emphysematous pyelonephritis, and when we say pyelonephritis,

40:24

that means it's in the parenchyma, and then it can, like

40:28

I just showed you, go beyond the parenchyma as well.

40:34

Again, high prevalence of diabetes

40:37

in patients with this diagnosis.

40:39

Gas formation, E. coli, most common.

40:43

And it can be life-threatening.

40:50

Although this doesn't look much like a

40:52

gallbladder because it has all this stuff in it,

40:56

this is a gallbladder, and it has non-dependent

41:00

echogenic material with associated dirty shadowing.

41:04

Here's another image of it.

41:06

Okay, so gas.

41:08

The patient had a history of diabetes

41:10

and right upper quadrant pain.

41:12

And this is their CT.

41:14

There is gas in the gallbladder and there is also

41:18

some gas in the wall of the gallbladder as we followed it.

41:21

There were inflammatory changes around the gallbladder.

41:26

And this is emphysematous cholecystitis.

41:32

Again, urgent.

41:34

And we can confirm with CT if there's

41:36

any question if you're ever stuck.

41:38

I would just say go to CT.

41:41

You get a fast answer.

41:44

So our differential for shadowing from the gallbladder,

41:47

gallstones, pneumobilia, and pneumobilia,

41:51

in itself, oftentimes is benign, if, you know,

41:54

there's been a prior history of a stent or if there's

41:56

been some anastomosis

41:59

with bowel, an arterial biliary anastomosis.

42:03

So you want to know what the history is.

42:05

In our particular patient, though,

42:07

that was emphysematous cholecystitis.

42:09

And then shadowing can also come from the

42:11

gallbladder wall, from porcelain gallbladder.

42:15

So just to show you some of these signs.

42:17

This is a wall echo shadow sign of cholelithiasis.

42:21

So this is a gallbladder that's full of

42:24

gallstones, and we can kind of see this bumpy

42:26

surface here with a little bit of residual bile.

42:29

We can see shadowing.

42:31

And then this is the wall.

42:32

Wall echo shadow.

42:35

These are gallstones.

42:37

This, on the other hand, is gas.

42:41

This is gas, and we can see non-

42:43

dependent echogenicity with dirty shadowing.

42:48

This is a porcelain gallbladder, and we can

42:51

actually follow the wall of the gallbladder.

42:53

There's linear calcification in it.

42:55

It's not real heavy calcification because we can actually

42:58

see through it, and we see the posterior wall as well.

43:01

This patient had a CT as well,

43:03

and this was a porcelain gallbladder.

43:06

And then, one other that kind of falls into

43:08

this category, I just wanted to go over,

43:11

is adenomyomatosis of the gallbladder, which is a benign

43:14

finding, but you get these comet tail artifacts. You can

43:17

see that's different than the other three.

43:21

Adenomyomatosis.

43:26

Our last category then is acute hemorrhage.

43:30

This was an outpatient who came in.

43:33

She was just getting her regular,

43:36

surveillance for cirrhosis, and she had had

43:39

many, you know, multiple ultrasounds before.

43:44

When we looked at her spleen, there was

43:45

something new, a heterogeneous mass in her spleen.

43:52

We always, always turn on color.

43:56

Okay.

43:56

So we did, and we could see that

43:58

there was flow in this mass.

44:00

And then you start to think, well,

44:01

did she have some trauma?

44:03

Is this related as a pseudoaneurysm?

44:05

Or is this some sort of a hypervascular mass?

44:08

She didn't give a history of trauma at the time

44:11

to the sonographer, but we said we better do, we

44:14

better evaluate this further, which we did, and

44:18

unfortunately, um, she did, um, have, she did have a,

44:24

a large bleed around her spleen, you can see she has

44:26

huge splenomegaly because she's, she's got cirrhosis,

44:29

very, um, very nodular liver, ascites, and this is

44:33

what we were looking at on the ultrasound exam.

44:36

So, this did turn out to be a pseudoaneurysm.

44:38

An important point there.

44:41

I think one of them is always turn on color.

44:44

Okay, and when she was questioned further,

44:46

she apparently had some minor trauma, like, uh, several

44:50

weeks before, and she didn't make much of it.

44:52

She ended up having that embolized.

44:58

Okay, I'd like to wrap it up now by just,

45:01

uh, kind of highlighting what we just

45:03

talked about, our "can't miss" diagnoses.

45:06

So, the first one we talked about was ectopic

45:09

pregnancy, and remember, in our patient, we

45:12

had a large amount of hemorrhage in the pelvis.

45:15

She had a positive pregnancy test.

45:17

We actually found this tubal ring sign in her.

45:24

Our next is ovarian torsion.

45:26

Remember our patient that has had this markedly enlarged,

45:30

I think it was greater than a six-centimeter ovary.

45:33

That has peripheral follicles and heterogeneous

45:36

echogenicity within the parenchyma.

45:38

We did talk about Doppler imaging and

45:43

how patients can still have some residual

45:47

Doppler flow in their ovary when it's torsed.

45:51

And the grayscale finding is very important.

45:53

Remember the most consistent

45:55

finding is an enlarged ovary.

46:01

We also talked about PID and tubovarian abscesses.

46:07

It's important to have the history here.

46:08

You certainly would want to know how tender they are.

46:11

Do they have a white count?

46:12

Do they have a fever?

46:13

Do they have a history of pelvic inflammatory disease?

46:16

But here is the uterus with this complex fluid

46:19

collection that turned out to be an abscess.

46:25

And then moving to testicular torsion.

46:28

So, side-by-side imaging,

46:30

so important with color Doppler.

46:32

And this was left testicular torsion.

46:35

We did review the imaging on a patient that

46:38

still had some residual flow in their

46:42

testicle that was torsed, but that there was

46:45

a symmetric decreased color Doppler flow in the

46:49

torsed testicle with color Doppler imaging.

46:54

And you can also look for the twist

46:56

necrotizing fasciitis, GAS, is so important for us

47:03

to be able to recognize on ultrasound.

47:06

And this is an extremely important diagnosis

47:09

for us to make and communicate urgently.

47:15

We also talked about other necrotizing infections.

47:18

Testicular trauma, we look for tunica disruption.

47:25

And sometimes, though,

47:28

it's not quite so obvious as this.

47:30

And here we can actually see tunica disruption

47:33

and we see the extruded seminiferous tubules.

47:36

Again, important for us to diagnose because the

47:41

surgery is best performed within 72 hours.

47:48

We talked about liver transplant, artery stenosis,

47:52

with a parvus tardus waveform, and a low resistive index.

47:58

And so the hepatic artery

48:01

is what is very important here.

48:03

And it's the spectral wave analysis of the hepatic artery.

48:08

When we see this waveform, we are most concerned

48:11

about either hepatic artery stenosis or thrombosis.

48:16

If you're obtaining this from the intrahepatic

48:20

branches, that may have collateralization.

48:25

Renal transplant vein thrombosis.

48:27

So when we see this high resistive with reversed

48:31

diastolic flow waveform in the renal artery, our number

48:35

one diagnosis of exclusion, especially around the

48:38

perioperative setting, is renal vein thrombosis.

48:44

And then our last patient that we

48:48

just looked at, pseudoaneurysm with bleed.

48:52

And, you know, always remember to put on color Doppler.

48:56

It will help you, um, not miss diagnoses like these.

49:02

I'd like to thank you very much for your attention.

49:05

I hope this was helpful for you.

49:08

And I have included my contact information

49:11

here, my email, and also Twitter handle.

49:14

Feel free to contact me if you have any questions.

49:20

Okay.

49:21

Okay.

49:25

It looks

49:26

like we do have one question in the Q&A function.

49:29

Okay.

49:30

Okay.

49:30

How to diagnose prepu, um, I think we got one more.

49:36

Okay.

49:36

Okay.

49:36

How to diagnose a prepu at all, um,

49:42

Is it PCOS?

49:44

Is that what I, I'm, I guess I might, I'm not, maybe if

49:48

the person could just put in what they meant

49:52

by PCOD, um, as a predisposition to torsion, um, PCOS.

49:58

Okay.

49:58

Thank you.

49:59

Um, yeah, so PCOS as a predisposition to torsion, um, so PCOS

50:05

in, um, in general, and I, I will say I am more of an adult

50:11

sonographer than pediatric, although I

50:15

have done, um, a bit of a lot of pediatric

50:18

ultrasound imaging in the past, but I will take

50:21

this to adults right now as I'm talking about it.

50:24

So when I look at PCOS, um, the

50:26

findings are generally symmetric.

50:28

So the ovaries, if they're enlarged and they have multiple

50:31

peripheral follicles, they're generally, um, symmetric.

50:35

And with PCOS, it would be highly unusual

50:41

to have bilateral testic, I mean, um, ovarian torsion.

50:45

And so I'm looking for asymmetry of size.

50:49

And then I'll be looking

50:51

at the color Doppler, um, as well.

50:53

Although I know, as we mentioned, you

50:56

can still have color Doppler imaging.

50:58

So to me, is the process bilateral and symmetric?

51:02

Or is it asymmetric and the patient is having, you know,

51:06

say pain on the right side, and the right ovary is a

51:09

lot larger than the left, although both of them are

51:12

slightly enlarged, um, then I would be more

51:15

leaning towards, um, ovarian torsion if there's asymmetry.

51:18

The other thing is, is there an underlying mass,

51:21

um, such as a dermoid or something else that

51:24

would also predispose the ovary to torsion?

51:29

So I hope that was helpful, and please feel free to,

51:32

um, contact me if you still have questions.

51:34

Feel free, you know, to contact me via

51:36

email and I can, um, we can go into more detail.

51:40

Um, let me see.

51:41

I have a question.

51:44

Next question is, um, a retrograde waveform in

51:47

a transplant kidney means renal vein thrombosis.

51:50

So that's my main concern when I see it.

51:53

Now there can be accelerated, let's just say

51:56

it's, uh, within a week of the transplant,

51:59

there could be accelerated acute rejection that

52:01

could also, um, give a retrograde flow.

52:06

So that's also possible.

52:08

My main thing, though, is I want to find

52:10

the renal vein and see if there's

52:14

normal flow in the renal vein or not.

52:15

If there's normal renal vein flow, I'm not,

52:18

then that retrograde flow is due to something else.

52:21

But that's the main diagnosis of exclusion.

52:26

Okay.

52:29

Next one is the waveforms of renal vein thrombosis

52:32

and renal pseudaneurysm are similar to and fro.

52:39

Is there a way?

52:42

to distinguish a small pseudoaneurysm

52:45

versus a renal vein thrombosis?

52:47

So, um, when I think about renal, um, transplant

52:51

pseudoaneurysms, the typical history I think of is

52:54

somebody that's had a biopsy and, um, would develop, uh,

52:59

pseudoaneurysm or an AV fistula related to the biopsy.

53:05

Um, typically, uh, more in the parenchyma.

53:08

Um, so that would be, um, what I typically would

53:12

be thinking of, and yes, in a pseudoaneurysm, um,

53:17

there will be two in for, um, for a flow, uh, with

53:21

renal vein thrombosis, there's oftentimes no flow.

53:27

So, um, next one is how to differentiate between

53:30

a ruptured tubal ectopic versus a ruptured, this

53:33

is a really good question, ruptured hemorrhagic.

53:35

There are a lot of different ways to differentiate system.

53:38

I'll just say they've all been great questions.

53:40

Um, this is a clinical, um, this

53:42

is a common clinical scenario.

53:43

I'll say, um, is when we see something

53:46

complex in the adnexa, we're trying to

53:49

decide, is it owned by the ovary or not?

53:52

Okay.

53:52

So is it in the ovary or is it in the

53:55

tube that, you know, outside of the ovary?

53:57

And, um, if it's in the ovary, it's true

54:02

that ectopics can rarely occur in the ovary.

54:06

Um, but, um, much more common to be

54:09

an ectopic if it's not in the ovary.

54:12

Now, how do you distinguish between,

54:14

what if it's really close to the ovary?

54:16

How do you tell?

54:17

One of, um, I like to look for the slide sign.

54:19

Uh, so one thing that you can do is while you're,

54:22

um, performing the transvaginal scan, you can

54:26

put some pressure on the patient's pelvis.

54:29

In that area and see if you can separate

54:32

the complex mass that you're seeing

54:35

from the ovary.

54:36

If you can separate the two, then you can say it's

54:38

separate from the ovary and it's going to be an ectopic.

54:42

Okay.

54:43

If you can't separate, and let's just say you

54:45

just can't tell and it's, if it's ruptured, um,

54:51

and there's a lot of blood, then, um, it'll really

54:55

be, that's the time that I would be talking to, um,

54:58

the obstetrician and saying, this is what I see.

55:00

I just can't tell for sure.

55:02

We might do a very short interval, um, follow-up.

55:04

It would be, you know, then it becomes

55:07

a little bit more of a clinical decision.

55:09

But usually, usually as we work through it,

55:12

we can kind of tell, especially if we're,

55:14

especially if we can separate it from the ovary.

55:18

And then there's one last question, um, which

55:21

is torsion detorsion versus epididymitis.

55:24

This I also have encountered.

55:27

Again, these are all great questions,

55:29

all of the questions that were asked.

55:31

And, um, the story is different.

55:34

Um, fortunately, if I'm talking to in

55:37

a, so I go, I like to go in and scan.

55:39

Okay.

55:39

I do a lot of scanning and it really helps me

55:42

because I, I have a chance to talk to the patient,

55:46

interact with the patient, see how much, you know,

55:48

it really gives me a feel if I'm scanning, like

55:50

how much pain are they actually, are they having?

55:52

And what is their history?

55:54

Um, torsion, detorsion, um, they,

55:58

when they detorse, they feel better.

56:01

And so they might give the history of abrupt

56:03

onset of pain and then it started to get better.

56:06

And so then we see this hyperemic, um, testicle

56:10

and epididymis and, um, we say, well, you

56:14

know, this may be due to detorsion, right?

56:17

Um, where instead of the other thing you

56:20

would be considering is epididymitis.

56:22

Okay, so, um, so I, talking to the

56:25

patient really helps me with that.

56:27

With epididymitis, usually the pain, it just keeps going

56:31

along, it doesn't go away, um, as it does with detorsion.

56:38

I have already, um, been able to scan patients that

56:41

were, um, uh, that detorsed, um, or actually a, a

56:46

patient that, um, had, uh, done a manual detorsion,

56:49

um, in the emergency department and then sent the

56:52

patient to us to scan and, um, and seen the hyperemia.

56:57

But it's usually the history that

56:59

I get that really helps with that.

57:05

How common is it to see thrombotic pelvic

57:08

varices and pelvic congestive syndrome?

57:11

I actually don't know the answer to that.

57:14

I don't think I've seen it very often.

57:16

And I don't know the specific, you

57:18

know, I don't know how often it is.

57:20

So that I would have to, I'd probably have to look up.

57:25

And I think, are there any other questions?

57:33

Well, that seems like that might be it.

57:36

Um, as we bring this to a close, I want to thank

57:39

Dr. Deitte for this lecture.

57:40

And, uh, thanks to all of you for

57:42

participating in our new conference.

57:44

A reminder that this conference is

57:45

available on demand on MRIonline.

57:48

com in addition to all previous noon conferences.

57:52

There will not be a noon conference on Monday

57:54

due to the holiday, but be sure to join us

57:56

again on Wednesday for a lecture from

57:58

Dr. Andrew Schweitzer on imaging PRES, RCVS, and CNS vasculitis.

58:04

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58:07

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58:12

for updates and reminders on upcoming new conferences.

58:15

Thanks again and have a great day.