Category: Clinical Cases

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Case 58: Large Volume Paracentesis

Angela Wang, Benjamin Liotta

A 66-year old male with a longstanding history of alcoholic cirrhosis presents to the ED early in the morning requesting a paracentesis with 10 days of worsening abdominal distention in the setting of running out of his home furosemide several weeks prior. He denied fever, nausea, vomiting, or abdominal pain. 

 Vitals:  BP 151/99, HR 101, RR 20, T 97.6F, SpO2 100% 

On exam, his abdomen was grossly distended with a positive fluid wave and no peritoneal signs. His last paracentesis was done 2 weeks prior with 10L of fluid removed. IR was consulted but would not have availability until late afternoon, and after discussion with the patient, a paracentesis was performed in the ED. Ultrasound was used to visualize the fluid pocket and patient anatomy, to minimize risk to the patient. 

Figure 1: Perihepatic view. Cirrhotic, nodular liver and visible Morison’s pouch. The pocket of ascitic fluid visualized is approximately 5cm deep 

Figure 2: Transverse pelvic view, hyperechoic bowel loops can be visualized, as well as a 8-10 cm deep fluid pocket 

Figure 3: Limited left upper quadrant view. While the splenorenal space can be visualized, the perisplenic space, where ascites tends to preferentially accumulate (over the splenorenal space), cannot be seen in this image. 

Therapeutic and diagnostic paracentesis for ascites is commonly performed in the ED. The most common etiology for ascites is alcoholic cirrhosis, which makes up 80% of cases in western countries¹. Other causes include malignancy and heart failure¹. Prior to widespread use of ultrasound for routine bedside exams, paracenteses in the ED were commonly performed based on landmarks and could be associated with complications such as bleeding and damage to surrounding structures. A 2005 clinical trial showed the benefits of using ultrasound to guide needle placement during this procedure, with the authors finding a 95% success rate (defined by fluid aspiration) when ultrasound was used compared to a 68% success rate with the traditional technique⁵. A 2013 article also found that the use of ultrasound in paracenteses was associated with a 68% decrease in bleeding-related complications compared to the traditional technique⁴. 

A 2019 position statement by the Society of Hospital Medicine establishes recommendations for effective use of ultrasound to guide paracentesis. Ultrasound allows both identification of more superficial blood vessels to avoid with needle insertion as well as visualization of the peritoneal cavity to survey the anatomy and qualitatively and quantitatively describe any fluid within. Damage to abdominal wall vessels such as the inferior epigastric artery or vein can cause catastrophic bleeding, morbidity, and mortality². Identification of these vessels with color doppler prevents inadvertent vessel wall injury. As the ultrasound beam is only several millimeters wide, it is important to obtain views of multiple angles of the needle insertion site to ensure there are no vessels or underlying structures along the path of the needle².

Ascitic fluid is hypoechoic, while bowel is often hyperechoic due to bowel gas. Organs may be more heterogenous and of intermediate echogenicity³. Ultrasound can also be used to assess the fluid pocket itself. For example, a fluid depth of 2cm is recommended for procedural safety³. Ultrasound is more sensitive than x-ray to fluid as it is able to detect as little as 100 ml of fluid, compared to 500 ml for x-ray². Presence of heterogeneity within the fluid pocket can be suggestive of loculations, which may indicate a more likely malignant or inflammatory cause of ascites. 

The 66-year-old patient above had an uncomplicated paracentesis with needle placement in the left lower quadrant, and over 8 liters of fluid were removed from his abdomen. He tolerated it well and was discharged from the ED shortly after with follow-up with his PCP as well as a recommendation for regularly scheduled paracenteses with radiology. 

References:

1. AGA Clinical Practice Update on the Management of Ascites, Volume Overload, and Hyponatremia in Cirrhosis: Expert Review Orman, Eric S. et al. Gastroenterology, Volume 169, Issue 7, 1547 - 1557 

2. Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP; Society of Hospital Medicine Point-of-care Ultrasound Task Force; Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E7-E15. doi: 10.12788/jhm.3095. PMID: 30604780; PMCID: PMC8021127. 

3. Kumar A, Dancel R, Galen BT et al. Ultrasound Guidance for Paracentesis. N Engl J Med. 2022;386(7):e15. doi:10.1056/NEJMvcm2119156 

4. Mercaldi CJ, Lanes SF, Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. (2013). Chest, 143(4), 1010–1015. https://doi.org/10.1378/chest.12-0447 

5. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May;23(3):363-7. doi: 10.1016/j.ajem.2004.11.001. PMID: 15915415. 

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Case 57: Positional Vertigo in the ED With Incidental Interatrial Shunt on Bubble Study

Carmon Controy, Akash Desai

44 y.o. male, brought by EMS from an outpatient procedure suite after sudden onset vertigo and gait instability following a right TMJ/ CNIII V3 injection. Patient experienced abrupt dizziness described as imbalance with ataxic gait, nausea, and one episode of emesis. The symptoms worsen with head movement/position change and improve at rest. No focal weakness, speech change, or headache reported. 

Pertinent PMHx: HIV on ART; cognitive impairment on donepezil/memantine; lumbar stenosis s/p L5–S1 decompression. Prior episodes concerning for TIAs/CVAs. 

Pertinent FHx: Patient states his father had a “hereditary hole in his heart” which was an incidental finding in his adult life, corrected with surgery.  

Vitals on Arrival: BP 146/88, HR 91, RR 16, SpO₂ 98% RA, afebrile 

Physical Examination:

  • General: No distress. 
  • Neuro: Alert/oriented; cranial nerves grossly intact; strength/sensation intact; left-beating nystagmus noted initially; abnormal ataxic gait on arrival. 
  • Cardiopulmonary/Abdomen: Unremarkable. 

ED Imaging and Tests:

  • CT/CTA Head & Neck (stroke protocol): No hemorrhage, large territorial infarct, LVO, or significant stenosis. 
  • MRI Brain (DWI): “Questionable subtle punctate” diffusion restriction in the left thalamocapsular region—artifact favored; tiny acute ischemic focus possible. No hemorrhage or mass effect. 
  • Neurology Consult: Vertigo most consistent with peripheral cause (positional trigger, brief episodes, improvement). HINTS/Dix-Hallpike negative when re-examined after symptom improvement. 
  • Labs: CBC/BMP/coags unremarkable. 
  • Cardiac Ultrasound: Transthoracic Echo with Agitated Saline (Bubble Study)
    • Normal LV size and EF ~54%; mild concentric LVH; normal RV size/function; no significant valvular disease. 
    • Bubble study positive: At rest, microbubbles appeared after 6–7 cardiac cycles; with Valsalva, a large, uncountable shower of bubbles traversed to the left heart—consistent with an interatrial shunt (e.g., PFO/ASD).

ED Course

Symptomatic therapy was provided (e.g., meclizine). Neurological symptoms improved during observation. Neurology judged low suspicion for central vertigo; recommended Epley if recurrent and discharge if symptoms resolved. Comprehensive stroke labs and imaging obtained. TTE with bubble study was positive for interatrial shunt as above, prompting recommendation for outpatient follow-up (stroke clinic/cardiology) to risk-stratify and discuss closure versus medical management in the context of prior suspected cerebrovascular events. 

Clinical course and neurology consultant assessment favored positional peripheral vertigo (likely posterior canal BPPV precipitated by head positioning during the OP nerve block procedure) over central causes; neuroimaging was equivocal for a tiny thalamocapsular DWI focus. However, the positive bubble study establishes an interatrial right-to-left shunt, providing a plausible pathway for paradoxical embolism. In a patient with a reported history of likely TIAs/CVAs (including possible TIA at the time of current evaluation), this finding heightens stroke risk considerations and may influence long-term secondary prevention (antithrombotic strategy) and candidacy for shunt closure after more thorough outpatient stroke-neurology/cardiology evaluation. 

Discussion 

This presentation is most consistent with peripheral, positional vertigo; the positive agitated-saline study is therefore best viewed as incidental to today’s symptoms.¹,² That said, a PFO is common (~20–25% of adults) and provides a plausible conduit for paradoxical embolism (especially when shunting becomes prominent with Valsalva), so its relevance is probabilistic and depends on clinical context rather than timing alone.³,² Frameworks like the Risk of Paraxodical Embolism (RoPE) score weigh age, event phenotype, and vascular risk factors to estimate whether a PFO is likely pathogenic versus incidental.⁴,⁵ Larger shunt burden and high-risk anatomy (e.g., atrial septal aneurysm) increase suspicion, while alternative mechanisms (occult AF, atherosclerosis, dissection, thrombophilia) must be assessed in parallel.⁶,⁵ 

For secondary cerebrovascular prevention, guideline-concordant work-up (e.g., rhythm monitoring for AF; targeted DVT evaluation; selective hypercoagulability testing) should inform therapy.⁷,⁶ In carefully selected patients 18–60 with a recent non-lacunar ischemic stroke of undetermined cause and a high-risk PFO, randomized trials (RESPECT long-term, CLOSE, REDUCE) show reduced recurrent stroke with percutaneous closure plus antiplatelet therapy compared with antiplatelet therapy alone, albeit with a small increase in atrial arrhythmias;⁸,⁹,¹⁰,¹¹ outside these criteria, optimized medical therapy is appropriate and decisions should be shared between stroke neurology and cardiology.⁶ Bottom line: (1) the PFO is likely incidental to this vertigo episode; (2) given prior TIAs/CVAs without a clear alternative mechanism, the PFO may have contributed to earlier events; and (3) the finding warrants formal risk stratification and guideline-based discussion of closure vs. medical therapy.⁴,⁵,⁶ 

References

  1. Collins S, Guntheroth WG, Raghu G, et al. Agitated saline contrast echocardiography: Contraindications, complications, and safety. J Am Soc Echocardiogr. 2022;35(1):13-21. doi:10.1016/j.echo.2021.10.016 
  1. Abdelmoneim SS, Mulvagh SL, Porter TR, et al. The clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update. J Am Soc Echocardiogr. 2018;31(3):241-274. doi:10.1016/j.echo.2017.11.013 
  1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17-20. doi:10.1016/S0025-6196(12)60336-X 
  1. Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Ann Intern Med. 2013;158(5):285-292. doi:10.7326/0003-4819-158-5-201303050-00004 
  1. Kent DM, Dahabreh IJ, Ruthazer R, et al. Device closure of patent foramen ovale in patients with cryptogenic stroke: RoPE-estimated attributable fraction and treatment effect. Stroke. 2020;51(7):2143-2150. doi:10.1161/STROKEAHA.119.028966 
  1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375 
  1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. doi:10.1161/STR.0000000000000024 
  1. Saver JL, Mattle HP, Thaler DE. Patent foramen ovale closure versus medical therapy for cryptogenic ischemic stroke: a topical review. Stroke. 2018;49(6):1541-1548. doi:10.1161/STROKEAHA.117.018153 
  1. Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377(11):1022-1032. doi:10.1056/NEJMoa1610057 
  1. Mas J-L, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelet therapy after stroke (CLOSE). N Engl J Med. 2017;377(11):1011-1021. doi:10.1056/NEJMoa1705915 
  1. Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke (REDUCE). N Engl J Med. 2017;377(11):1033-1042. doi:10.1056/NEJMoa1707404 
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Case 56: Udderly Blinded: A Case of Chronic Ocular Trauma Unmasked by POCUS

Martin Day, Elaine Yu

A 69-year-old male with no significant past medical history presented to the emergency department after striking his right eye with the handle of a spray hose at work. He reported burning pain but denied bleeding, tearing, or other injuries. Eye movement did not exacerbate the pain. Notably, he had been chronically blind in the right eye since childhood after sustaining blunt ocular trauma from being kicked by a cow around age 12. He described no perception of light in that eye since then.

Vitals: BP 138/83 | Pulse 85 | Temp 98.4F (36.9C) | Resp 17 | SpO2 98%

Physical Exam:

On physical examination, the patient was alert and cooperative, not in acute distress. The right eye did not demonstrate periorbital ecchymosis or signs of obvious trauma. There was negative fluorescein uptake, extraocular movements intact, and pupil fixed. He had no light perception. His left eye was normal on examination.

A bedside ocular ultrasound was performed:

Figure 1. Bi-convex lens with hyperechoic but irregular borders.

Figure 2. Ocular ultrasound depicting hyperechoic debris within the posterior chamber and vitreous hemorrhage, represented as materials of varying echogenicity within the vitreous body.

ED Course

Pain was treated conservatively with topical anesthetics and fluorescein for exam. Patient did not require any acute intervention. He was reassured, educated on return precautions, and discharged in stable condition.

Discussion

Blunt ocular trauma can cause profound and often irreversible injury. In this patient, a cow kick to the eye at age 12 resulted in permanent blindness. Decades later, a new minor injury prompted re-evaluation, but his underlying chronic pathology was the dominant finding.

Despite an apparently benign surface exam—negative fluorescein, intact EOMI, no external trauma—ultrasound revealed chronic posterior segment pathology: vitreous detachment, hemorrhage, and irregular lens, consistent with his long-standing blindness. Notably, POCUS excluded emergent findings such as global rupture or retinal detachment.

The American College of Emergency Physicians recommends POCUS for assessing the posterior segment of the eye. Multicenter trials and meta-analyses convey high sensitivity and specificity for retinal detachment (96.9% sensitivity, 88.1% specificity), moderate diagnostic accuracy for vitreous hemorrhage (81.6% sensitivity, 82.3% specificity), and lower sensitivity (42.5%) but high specificity (96.0%) for vitreous detachment [1,2,3,5]. Additionally, POCUS was 100% sensitive and 97% specific for lens dislocation, and 100% sensitive and 99% specific for intraocular foreign body according to another meta-analysis [1,5].

Vitreous hemorrhage appears on ocular ultrasound as a fluid collection of variable echogenicity within the posterior chamber of the globe. The hemorrhagic material typically is mobile, shifting as the patient moves their eye while the probe remains still [2]. In chronic cases, fibrotic changes may cause the echogenic fluid collection to appear denser and more organized [1,2]. Vitreous detachment appears as a mobile, hyperechoic membrane in the posterior chamber, like vitreous hemorrhage, during kinetic examination [3]. Retinal detachment can be differentiated from vitreous detachment because it appears more echoic and anchored to the optic disc, which was not appreciated in this case [2,3]. The lens on ocular ultrasound may appear irregular in its position or contour [3]. This patient’s lens appeared typically centered behind the iris without evidence of dislocation. However, the margins were poorly defined, with irregular, asymmetric borders, suggestive of a lens irregularity [3,6].

In emergency medicine, ocular ultrasound offers a quick and effective means of evaluating both acute injuries and chronic sequelae. This case highlights the value of ultrasound in diagnosing both acute and chronic ocular pathology. It allows rapid, non-invasive assessment of posterior structures even when vision is absent or the anterior exam appears normal. A visit to the ED for a minor workplace incident uncovered sequela of a childhood injury. Additionally, clinical judgment helped guide diagnosis. With no suspicion of intraocular foreign body or orbital fracture, CT was deemed unnecessary. Ultrasound was sufficient to distinguish chronic from acute findings.  POCUS may be especially useful for assessing unreliable historians. POCUS does not replace the comprehensive ophthalmologic evaluation [4]. Nonetheless, it serves as a crucial tool for rapid bedside assessment for urgent intervention [4].

References

  1. American College of Emergency Physicians. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Irving, TX: American College of Emergency Physicians; 2023.
  2. Lahham S, Shniter I, Thompson M, et al. Point-of-care ultrasonography in the diagnosis of retinal detachment, vitreous hemorrhage, and vitreous detachment in the emergency department. JAMA Netw Open. 2019;2(4):e192162. doi:10.1001/jamanetworkopen.2019.2162
  3. Pyle M, Gallerani C, Weston C, Frasure SE, Pourmand A. Point of care ultrasound and ocular injuries: a case of lens dislocation and a comprehensive review of the literature. J Clin Ultrasound. 2021;49(3):282-285. doi:10.1002/jcu.22904
  4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. doi:10.1111/j.1553-2712.2002.tb02166.x
  5. Propst SL, Kirschner JM, Strachan CC, et al. Ocular point-of-care ultrasonography to diagnose posterior chamber abnormalities: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(2):e1921460. doi:10.1001/jamanetworkopen.2019.21460
  6. Özdal M, Mansour M, Deschênes J. Ultrasound biomicroscopic evaluation of the traumatized eyes. Eye (Lond). 2003;17(4):467-472. doi:10.1038/sj.eye.6700382
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Case 54: Point-of-Care Ultrasound in Polycystic Kidney Disease with Hepatic Involvement

EJ Curtis, Colleen Sweeney, Colleen Campbell

A 70-year-old man with a past medical history of hypertension, obstructive hypertrophic cardiomyopathy, atrial fibrillation status-post Watchman procedure, and end-stage renal disease secondary to polycystic kidney disease (status-post renal transplant in 2014, complicated by chronic kidney disease stage 5 of the transplanted kidney) was brought to the emergency department after being found on the floor by his daughter. On arrival, the patient had generalized weakness, lightheadedness, and epigastric pain.

Vital signs: BP: 77/60 mmHg | HR: 103 | RR: 20 | T 37.3C

On physical exam, the patient appeared chronically ill and had scattered ecchymoses on bilateral upper extremities which he attributed to the recent fall. He also had bilateral lower extremity pitting edema which he says is stable since stopping furosemide. His abdomen was tender to palpation in the epigastric region with no rebound or guarding.

A bedside ultrasound was performed to evaluate for the source of abdominal pain.

Figure 1. Hepatorenal Junction

Figure 2. Splenorenal Junction

Figure 3. Multi-cystic liver parenchyma

Discussion:

Blood cultures grew out pseudomonas aeriginosa.  Patients with PKD can get septic from infected cysts however the source of his infection was not clear.

Polycystic kidney disease (PKD) is the most common inherited cause of end stage renal disease (ESRD) with the most common form, Autosomal Dominant PKD (ADPKD) affecting around 500,000 people in the United States and between 1 in 400 to 1 in 1000 births1. ADPKD is a progressive, multisystem disease associated with extrarenal manifestations of disease most associated with cysts in other organs such as the liver, seminal vesicle, and pancreas though connective tissue disorders including mitral valve prolapse, intracranial aneurysms, and abdominal hernias are also commonly reported2. Transplant of kidney is usually more successful after nephrectomy of native kidneys, with 1 year survival >90% and median survival of 18.7 years.

Polycystic liver disease (PLD), the most common extrarenal manifestation of PKD, is characterized by the presence of cysts in greater than 50 percent of the liver3. Between 75 and 90 percent of patients with ADPKD have associate PLD4. Notably, there is an inherited form of PLD, which is distinct from PKD but it is less common than PKD and is rarely associated with concurrent renal cysts 5.

The presence of innumerable hepatic cysts, as demonstrated in this case, provides a valuable sonographic teaching example for learners. It is critical to recognize that while renal disease is the primary driver of morbidity and mortality in ADPKD, extrarenal manifestations such as polycystic liver disease, intracranial aneurysms, and cardiac valvular disease are important contributors to patient outcomes and should be monitored and included as part of the differential diagnoses when these patients present to the emergency department. 

References:

  1. Mahboob M, Rout P, Leslie SW, Bokhari SR. Autosomal Dominant Polycystic Kidney Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Updated March 20, 2024. Available from: NCBI Bookshelf 
  2. Pirson Y. Extrarenal manifestations of autosomal dominant polycystic kidney disease. Adv Chronic Kidney Dis. 2010 Mar;17(2):173–80. doi:10.1053/j.ackd.2010.01.003 
  3. Henriques MSM, Villar EJM. Chapter 17: The Liver and Polycystic Kidney Disease. In: Li X, editor. Polycystic Kidney Disease [Internet]. Brisbane (AU): Codon Publications; Nov 2015. doi:10.15586/codon.pkd.2015.ch17 
  4. Harris PC, Torres VE. Polycystic kidney disease. Annu Rev Med. 2009;60:321–37. doi:10.1146/annurev.med.60.101707.125712 
  5. Cnossen WR, Drenth JPH. Polycystic liver disease: an overview of pathogenesis, clinical manifestations and management. Orphanet J Rare Dis. 2014 May 1;9:69. doi:10.1186/1750-1172-9-69 
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Case 53: Forgo the CT Scan: Utilization of Ultrasound In Conjunction With Clinical Tools In Diagnosing Acute Appendicitis

Jeremy Santiago, Anthony Medak

77-year-old female with a past medical history of diabetes mellitus and rheumatoid arthritis presented to the emergency department with 2 days of abdominal pain. Pt reports that she began feeling abdominal pain diffusely that has now moved to RLQ. States pain was worsened with movement, and she tried taking Pepto Bismol and Tylenol at home with no relief. She feels like her appetite has decreased due to the pain. She denies urinary symptoms, changes in bowel movements, nausea/vomiting, cough, fever, chills, chest pain, or back pain. Patient endorses she is currently taking methotrexate for her RA. Surgical hx notable for prior salpingo-oophorectomy and hysterectomy.

Vitals: BP 132/58 | Pulse 79 | Temp 98.4 °F (36.9 °C) | Resp 16 | Wt 52.2 kg (115 lb) | SpO2 100% | BMI 19.14 kg/m²

Physical Exam:

On physical examination the patient was alert and nontoxic appearing without any evidence of acute distress. The abdomen was soft, flat, and non-distended with tenderness to palpation in the RUQ and RLQ. There was no guarding, rebound tenderness, or evidence of peritoneal signs. There was positive McBurney point tenderness on exam, with a negative Murphy’s sign and Rovsing’s sign.

Labs: WBC 13.6, Lipase 9, U/A negative, CMP unremarkable.

Based on the history, physical examination, and labs, the Modified Alvarado score was 7, indicating probable/likely appendicitis. A focused bedside ultrasound examination of the RUQ and RLQ were conducted utilizing the curvilinear transducer.

Figure 1. Two separate dilated segments of the appendix were appreciated with periappendiceal fluid. A hyperechoic structure is noted within the lumen without shadowing concerning for possible appendicolith.

Figure 2. A longitudinal dilated segment of the appendix is visible with periappendiceal fluid.

Figure 3. CT abdomen and pelvis with contrast in axial and coronal views demonstrate acute appendicitis with a measured diameter of 9mm and associated fat stranding/periappendiceal fluid.

Discussion

Acute appendicitis is one of the most prevalent abdominal surgical emergencies worldwide with over 300,000 hospital visits reported annually within the U.S. alone [4,5]. Appendicitis is often a delayed or missed diagnosis, and one of the most common malpractice cases that Emergency Physicians face [2]. For many providers, the diagnostic accuracy of CT imaging, ability to detect other acute causes, and the fear of missing appendicitis are the reasons many providers opt for CT imaging in the workup of acute abdominal pain. Appendicitis can be characterized as uncomplicated or complicated based on presence of perforation, abscess, or necrosis in addition to histological findings. Management of acute appendicitis generally consists of medical, surgical, or combined modalities [4,5]. Although many institutions and societies have recommendations and guidelines for managing acute appendicitis with antibiotics alone, an appendectomy is the only definitive management, and patients often warrant prompt surgical evaluation.

The diagnosis of appendicitis is typically made utilizing clinical examination, laboratory markers, and imaging. Common symptoms include initial vague abdominal pain that localizes to the RLQ, anorexia, nausea with or without vomiting, diarrhea, and fever. Given the location of pain and non-specific symptoms associated with acute appendicitis, a broad differential diagnosis and additional workup should be considered [4,5,7].  CT imaging is considered the gold standard by The American College of Radiology and the most often preferred imaging modality by surgeons with an accuracy > 95%, (Sensitivity 91-96%, Specificity 90-95%) when compared to abdominal ultrasound (Sensitivity 78%, Specificity 83%) [5].  Ultrasound findings of acute appendicitis include appendiceal diameter >6mm, presence of appendicolith, increased periappendiceal fat stranding, and lack of appendix compressibility [4]. Risk stratifying tools such as the Modified Alvarado Score (MAS) can also be used to determine the likelihood of acute appendicitis without further imaging, with reported sensitivity and specificity up to 95% and 90% respectively, utilizing a cut off score of 7 [3,6,7].

Several studies have looked at the combination of MAS with abdominal ultrasound and demonstrated an increased sensitivity and diagnostic accuracy of acute appendicitis when utilized together. The combination of these two clinical tools to rule in appendicitis may save time, avoid unnecessary radiation, and subsequently reduce complication rates or negative appendectomies [1,3,6,7]. In the case of this patient, her clinical presentation and exam were consistent with acute appendicitis (MAS of 7). Bedside POCUS was notable for a dilated appendix with periappendiceal fluid and a possible appendicolith concerning for acute appendicitis. The positive POCUS findings in addition to MAS ≥ 7 made acute appendicitis very likely and her diagnosis was later verified on abdominal CT imaging.  Her negative urinalysis and prior history of total hysterectomy made genitourinary sources of symptoms less likely, thus blunting the alternative diagnostic benefits of CT imaging. She underwent an appendectomy and had confirmed acute appendicitis and periappendicitis with abscess formation on pathology. No appendicolith was identified on imaging or pathology however, despite our POCUS findings.

As POCUS availability and experience becomes more common amongst Emergency Medicine providers, the use of abdominal ultrasound in conjunction with risk stratifying tools such as the Modified Alvarado Score may be beneficial to rule-in acute appendicitis in uncomplicated patients for whom you have a high clinical suspicion. These tools may be especially useful in resource- limited settings or when obtaining CT imaging may significantly delay patient care.

References

  1. Al-wageeh, S., Alyhari, Q. A., Ahmed, F., Altam, A., Alshehari, G., & Badheeb, M. (2024). Evaluating the Diagnostic Accuracy of the Alvarado Score and Abdominal Ultrasound for Acute Appendicitis: A Retrospective Single-Center Study. Open Access Emergency Medicine, 16, 159–166. https://doi.org/10.2147/OAEM.S462013
  2. Chaudhary, Snehansh Roy, and Shambo Guha Roy. "The Diagnostic Uncertainties and Legal Precedents in Appendicitis Malpractice." Academic Radiology (2025).
  3. Kanumba ES, Mabula JB, Rambau P, Chalya PL. Modified Alvarado Scoring System as a diagnostic tool for acute appendicitis at Bugando Medical Centre, Mwanza, Tanzania. BMC Surg. 2011 Feb 17;11:4. doi: 10.1186/1471-2482-11-4. PMID: 21329493; PMCID: PMC3050681.
  4. Lotfollahzadeh S, Lopez RA, Deppen JG. Appendicitis. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493193/
  5. Moris D, Paulson EK, Pappas TN. Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA. 2021;326(22):2299–2311. doi:10.1001/jama.2021.20502
  6. Nasiri, S., Mohebbi, F., Sodagari, N. et al. Diagnostic values of ultrasound and the Modified Alvarado Scoring System in acute appendicitis. Int J Emerg Med 5, 26 (2012). https://doi.org/10.1186/1865-1380-5-26
  7. Sirpaili, Santosh MSa; Rajthala, Lilamani MSa; Banmala, Sabin MBBSb; Gautam, Pratima MSa; Ranabhat, Sangita MSa; Ghatani, Sangita Raj BScc; Shrestha, Eruka Bachelor in Nursingd. Efficacy of modified Alvarado score combined with ultrasound in the diagnosis of acute appendicitis: a prospective analytical study. Annals of Medicine & Surgery 86(5):p 2586-2590, May 2024. | DOI: 10.1097/MS9.0000000000001932
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Case 52: The Role of FAST in Penetrating Thoracoabdominal Injury

Brandon Woo, Elaine Yu

A 28 year old male with unknown past medical history presented to the emergency department with a single gunshot wound sustained to the anterior chest just prior to arrival. He was brought in by family members who reported a witnessed traumatic gunshot wound to the chest by an unreported individual. The patient complained of trouble breathing and was severely agitated in the setting of pain. He required 75 mg IV ketamine for moderate sedation while obtaining vital signs, ultrasound, and intravenous access. The team prepared for urgent intubation in the setting of possible respiratory decompensation and activated massive transfusion protocol.

Vitals: BP 151/81 | Pulse 104 | Temp 97.8º F (36.6ºC) | Resp 27 | Wt 122.2 kg (269 lb 6.4 oz) | SpO2 93%

On physical exam, the patient was in acute distress and diaphoretic, reporting trouble breathing but speaking in full sentences. He was alert and oriented to person, place, and event. Primary trauma assessment: patent airway, rapid shallow breathing, and capillary refill less than 2 seconds. Secondary survey revealed an approximately 1 cm open wound with active bleeding to the subxiphoid region. There were no step-offs or deformities to the spine and no other obvious signs of trauma externally. There were equal breath sounds, and 2+ pulses were present in the radial and posterior tibialis arteries. The remainder of the exam was unremarkable.

A FAST exam was performed to evaluate for free fluid, hemothorax, or pericardial effusion.

Figure 1: Subxiphoid view

Figure 2: RUQ view

Figure 3: LUQ view

Figure 4: Pelvic view (transverse).

Figure 5: Pelvic view (longitudinal).

Figure 6: Chest X-Ray

Discussion:

The extended Focused Assessment with Sonography for Trauma (eFAST) is a validated rapid, bedside trauma tool, classically validated in hemodynamically unstable patients with blunt trauma where delays in imaging may be fatal. However its use in penetrating trauma is situational. The sensitivity of ultrasound is significantly lower for bowel injury, retroperitoneal bleeding, and intra-abdominal bleeding [1]. This patient was hemodynamically stable, which typically decreases the urgency for bedside ultrasound. However the patient’s agitation, tachypnea, and uncertain injury trajectory of a subxiphoid entry wound made thoracic and abdominal evaluation critical.

The presence of pelvic free fluid (Figures 4,5) and tachycardia with hyperdynamic ventricles (Figure 1) raised concern for intra-abdominal injury and potential hemorrhage. The location of free fluid in a supine trauma patient is influenced by gravity, with the rectovesical or rectouterine pouch being common sites of accumulation [1]. This patient had been upright prior to arrival and was agitated and repositioned multiple times, raising the possibility that the visualized pelvic fluid was gravitational rather than an isolated pelvic organ injury.

Figure 7: Abdominal X-ray.

Free fluid was visualized only in the suprapubic view, which may be due to localized pelvic injury, supported by the bullet location on KUB (Figure 7), or redistributed by gravity from another source, given that the patient had been upright and repositioned prior to evaluation. The absence of fluid in the right or left upper quadrants does not exclude intra-abdominal hemorrhage, particularly in the setting of penetrating trauma, where eFAST sensitivity varies significantly by region and injury type [1,2].  Retroperitoneal bleeding or bowel injury are often missed with eFAST alone, both possibilities in this case.

A meta analysis of over 24,000 trauma patients demonstrated eFAST sensitivity and specificity, respectively, for intra-abdominal free fluid (74%, 98%), pericardial effusion (91%, 94%), pneumothorax (69%, 99%) [2]. In the suprapubic view, sensitivity ranges from 80 - 90%, with specificity ~ 99%, and detection thresholds as low as 100 - 150 mL [2]. The RUQ view, Morison’s pouch, has a sensitivity 85 - 96% and specificity 98%, but typically requires at least 200 mL of fluid for reliable detection [2]. The LUQ view, splenodiaphragmatic space, demonstrates sensitivity 70 - 85% with specificity 98 - 99% [2]. These ranges reflect variations in body habitus, fluid pooling, and operator dependency. These views are widely taught per guidance of the ACEP Sonoguide [5].

A randomized controlled trial found that while FAST did not reduce mortality, it significantly improved workflow and led to a faster time to diagnosis, fewer CT scans, shorter hospital stays, and lower costs [3]. Additional studies have shown that even when eFAST yields false negative results, outcomes are favorable as long as patient status is closely monitored and reassessed [4]. These statistics demonstrate eFAST’s strength in ruling in injuries when positive, but its limitations in ruling out injuries when negative, especially in penetrating trauma, where sensitivity can range from 28-100% depending on trajectory, organ involved, and injury severity [5]. 

In this case, eFAST was used as an adjunct to clinical decision making, not a replacement for formal imaging or serial exam. Its findings enabled structured handoff, avoiding unnecessary invasive interventions, and highlighted how point-of-care ultrasound can be safely integrated into trauma workflows even when patients fall outside classical indications. Additional data are needed to clarify how patient position prior to arrival, upright versus supine, affects the sensitivity and specificity of eFAST in trauma assessment, particularly in the evaluation of intra-abdominal free fluid. 

References:

  1. Tewari V, et al. The efficiency of focused assessment with sonography for trauma (FAST) vs. CT in penetrating torso trauma. J Emerg Trauma Shock. 2024;17(1):3–9.
  2. Netherton S, Milne WK, Proctor C, et al. Diagnostic accuracy of eFAST in trauma: a systematic review and meta-analysis. Can J Emerg Med. 2019;21(6):727–738.
  3. Stengel D, Bauwens K, Sehouli J, et al. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries: a randomized controlled trial. JAMA. 2017;317(11):1110–1119.
  4. Sierzenski PR, et al. Clinical outcomes after false-negative FAST in hypotensive trauma patients. BMC Emerg Med. 2023;23:45.
  5. American College of Emergency Physicians (ACEP). Trauma Ultrasound (eFAST). Sonoguide. Available at: https://www.acep.org/sonoguide/basic/fast
  6. https://www.bcpocus.ca/organscans/efast/
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Case 51: Utility of the Spine Sign in Detecting Pleural Effusion on POCUS

John Hermez

A 74 year-old male with a past medical history of metastatic castration-resistant prostate cancer complicated by cauda equina necessitating laminectomy decompression, chronic RLE DVT on apixaban and chronic hypotension presented to the emergency department accompanied by his spouse for altered mental status. Per the patient’s wife, he experienced cognitive decline and increasing weakness for one week prior to presentation. Two days prior to his arrival in the ED, the patient became more confused and agitated with his wife reporting that he appeared to be hallucinating intermittently. While he typically ambulates without assistance and straight-catheterizes himself, he has been unable to care for himself independently.

Vitals: BP 91/53 | Pulse 85 | Temp 98.1 °F (36.7 °C) | Resp 12 | Wt 92.3 kg (203 lb 7.7 oz) | SpO2 98% | BMI 29.1 kg/m²

Physical Exam:

On exam, the patient is in no acute distress and is oriented only to his name. He has diffuse anasarca with 2+ right lower extremity edema and 1+ left lower extremity edema. He is not pale or cyanotic and has shallow respirations on room air with diminished lung sounds and a flat JVP.

Labs: WBC 25.7 and initial lactate 2.2. Hb 9.5 PLT 98, Urine cloudy and orange, growth pending

ECG: NSR at 82 bpm with occasional PVCs, no evidence of ST changes

CXR: Compared to prior, there are new heterogenous bibasilar lung opacities and atelectasis possibly representing pneumonia. No definite pleural effusion or pneumothorax. Stable cardiac silhouette.

To clarify cardiac function and better characterize pulmonary status, a bedside point of care echocardiography was performed.

Figure 1: Trace pericardial effusion seen on parasternal short axis view.

Figure 2: Sagittal right sview demonstrating the thoracic spine sign

Discussion:

Radiographic imaging of the thorax is routinely performed in the ED to aid in the diagnosis of a wide range of cardiopulmonary manifestations. While upright chest x-rays are the Gold Standard for detecting pneumonia in patients, the detection of pleural effusion may be less clearly visualized. Meta-analysis has shown that the screening sensitivity of ultrasound may be 94% as compared to 51% for chest x-ray, in spite of having similar specificity.1 In this case, we rapidly obtained a point-of-care echocardiogram and pulmonary ultrasound to guide medical decision making in a patient with advanced metastatic disease and anasarca with equivocal radiograph.

A parasternal short axis view was obtained (figure 1) and demonstrated a trace pericardial effusion estimated to be 3mm without evidence of gross systolic dysfunction. Although the right ventricle was poorly visualized during diastole, the small volume of effusion and history of chronic hypotension was reassuring against tamponade physiology. Acquisition of a right subcostal view (figure 2) demonstrated the thoracic spine sign which is a reliable indicator of pleural effusion or hemothorax.2

Figure 3: Subcostal view labelled to identify anechoic pleural effusion (image courtesy of Stanford Medicine 25)5

The spine sign is a sonographic description of the visualization of vertebral bodies above the level of the diaphragm, which indirectly indicates that a thoracic fluid collection is present. When there is no thoracic free fluid present, an abrupt loss of the vertebral bodies occurs at the diaphragm due to air in the lungs impeding transmission.2 Pleural effusions and traumatic hemothorax can both represent fluid collections, hence the utility of subcostal imaging in the eFAST exam to evaluate thoracic trauma. One study on closed chest trauma has shown the absence of the spine sign to have a negative predictive value of 97.8% in assessing pleural effusion.3 The focused use of ultrasonography in the emergency department is regarded of high value in the early detection and diagnosis of multiple pathologies. Algorithmic exams such as the RUSH protocol provide rapid feedback on the physiology of a critically ill patient which can guide management and are recommended both by the American College of Emergency Physicians and Critical Care Societies.4 The potential applications of ultrasonography in resource-limited, austere environments by prehospital personnel are also of particular interest given novel advancements in AI-technology and focused training protocols.

In spite of a technically challenging exam, this case was an excellent example of the utility of multimodal imaging to clarify cardiopulmonary status in the ED. The patient was treated with broad antibiotic therapy for suspected urosepsis and admitted to the hospital for multidisciplinary care. He later was scheduled for therapeutic thoracentesis and surgical evaluation for a scapular fluid collection. 

References:

  1. Yousefifard M, Baikpour M, Ghelichkhani P, Asady H, Shahsavari Nia K, Moghadas Jafari A, Hosseini M, Safari S. Screening Performance Characteristic of Ultrasonography and Radiography in Detection of Pleural Effusion; a Meta-Analysis. Emerg (Tehran). 2016 Winter;4(1):1-10. PMID: 26862542; PMCID: PMC4744606.
  2. Dickman, E., Terentiev, V., Likourezos, A., Derman, A. and Haines, L., 2015. Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion. Journal of Ultrasound in Medicine, 34(9), pp.1555-1561.
  3. Vargas CA, Quintero J, Figueroa R, Castro A, Watts FA. Extension of the thoracic spine sign as a diagnostic marker for thoracic trauma. Eur J Trauma Emerg Surg. 2021 Jun;47(3):749-755. doi: 10.1007/s00068-020-01459-1. Epub 2020 Aug 17. PMID: 32803497.
  4. Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract. 2012;2012:503254. doi: 10.1155/2012/503254. Epub 2012 Oct 24. PMID: 23133747; PMCID: PMC3485910.
  5. “The Spine Sign.” Edited by Stanford Medicine 25 Bedside Medicine Symposium, Stanford Medicine 25, Stanford Medicine 25 Bedside Medicine Symposium, stanfordmedicine25.stanford.edu/blog/archive/2018/thespinesign1.html. Accessed 25 May 2025.
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Case 50: Ventral Hernia Pain

Bradley Phillips

A 47-year-old female with a medical history of right nephrectomy complicated by incisional “Swiss cheese” ventral hernias with recurrent incarceration and bowel strangulation presented to the ED with acute abdominal pain localized to the ventral hernia, nausea, and vomiting.

About three years earlier, the patient had undergone an exploratory laparotomy while admitted for peritonitis, which revealed an ischemic segment of small bowel and incarcerated omentum within a ventral hernia. She then underwent omentectomy, small bowel resection with primary anastomosis, and ventral hernia repair.

Following this surgery, the patient had recurrence of the hernia and frequent admissions for small bowel obstruction (SBO), all managed nonoperatively with nasogastric tube decompression and small bowel follow-through. She was discharged from the last such admission the day before presentation, and at that time was tolerating a liquid diet, passing flatus and having bowel movements. She believed that advancing her diet at home had triggered her symptoms, which included 6-7 episodes of non-bloody, non-bilious emesis following a solid meal.

Vitals: BP 128/83 mmHg | Pulse 103 | Temp 98.7 °F (37.1 °C) | Resp 16 | SpO2 93%

On physical examination, the patient was in acute distress and tachycardic. Abdominal exam revealed distension, tenderness in the periumbilical area, and guarding without rebound, as well as a large ventral hernia adjacent to a well-healed midline scar. The right side of the hernia was firmer than the left side but was mostly reducible.

A focused bedside ultrasound exam of the bowel was performed using the curvilinear transducer.

Figure 1. A dilated loop of small bowel, shown here in long axis, measures 3.78 cm in diameter. Bowel wall distension increases the visibility of the plicae circulares.

Figure 2: A loop of small bowel shown in long axis with bidirectional intraluminal content flow, also known as to-and-fro peristalsis.

Computed tomography of the abdomen showed dilated loops of small bowel measuring up to 3.9 cm with fecalization of the internal contents and a transition point at the anastomotic site at the hernia mouth, confirming SBO. There was no radiographic evidence of ischemia or perforation. General surgery was consulted. It was thought that the obstruction was likely due to adhesions or stenosis at the prior anastomosis and unrelated to the large ventral hernia.

The patient was admitted and treated conservatively with intravenous fluids and nasogastric tube decompression. Small bowel follow-through showed delayed passage of contrast and slow return of bowel function. She was discharged on a full liquid diet with planned follow-up with minimally invasive surgery for complex hernia repair.

Discussion

SBO is a significant cause of morbidity and hospital admissions. In the United States, the annual incidence of SBO is approximately 350,000 cases [1,2]. Prolonged obstruction can cause intestinal ischemia and necrosis of the bowel wall [3]. Combined with increased intraluminal pressure from the obstruction, this can lead to bowel perforation, peritonitis, and sepsis. The overall mortality rate for SBO is approximately 10%, but it can increase to 30% in cases complicated by bowel necrosis or perforation [1].

Adhesions are the most common cause of SBO, responsible for 65-74% of cases, and typically result from previous abdominal or pelvic surgeries. Other risk factors for SBO include hernias, neoplasms, Crohn disease, radiation enteritis, volvulus and foreign bodies [1,4].

Patients with SBO typically present with abdominal pain (often colicky and centrally located), nausea and vomiting, and constipation or obstipation. On physical examination, there may be abdominal distension. Early in the course of the obstruction, bowel sounds may be high-pitched and hyperactive. Advanced SBO can present with hypoactive or absent bowel sounds as well as severe abdominal tenderness with signs of peritoneal inflammation [1,5-6]. An elevated lactate supports clinical concern for bowel ischemia [7-8]. This patient’s lactate was normal at 1.1 mmol/L, although at the time of her episode of bowel strangulation and ischemia three years earlier, it was 2.5 mmol/L (elevated).

The differential diagnosis of SBO includes the myriad non-obstructive causes of nausea, vomiting, and abdominal pain; functional small bowel obstruction (adynamic ileus, pseudo-obstruction); and large bowel obstruction.

If SBO is suspected, the American College of Radiology recommends early imaging, particularly abdominal CT, to evaluate the severity of the obstruction, identify the etiology, and detect complications such as volvulus, strangulation, closed-loop obstruction, and ischemia [5]. However, point-of-care ultrasound (POCUS) has been shown to have a sensitivity of 83% to 92% and specificity of 93% to 96% in the evaluation of SBOs, and its use can save time and reduce radiation exposure [9,10].

When performing a POCUS exam for SBO, the curvilinear probe should be used for adult patients. The exam can be started at the patient-identified point of maximum tenderness, with the examiner applying graded compression to slowly and gently displace air out of the way of the probe. Segments of small bowel should be inspected in both long and short axis for dilation (diameter greater than 2.5 cm), absent or to-and-fro peristalsis, the presence of a transition point, free fluid, and bowel wall edema. Once an area of interest is identified, examiners can switch to the linear probe to increase image resolution [11].

The presence of a transition point is highly specific for SBO, as it is not seen in ileus. On ultrasound, a transition point will appear as an area of dilated bowel adjacent to an area of decompressed bowel. In the duodenum and jejunum, bowel wall distension can increase the visibility of the plicae circulares. An edematous bowel wall appears thickened on ultrasound with decreased echogenicity [11].

Management of small bowel obstruction (SBO) involves both nonoperative and operative strategies, depending on the patient's clinical presentation and response to initial treatment. Surgical intervention is indicated in cases of generalized peritonitis or signs of bowel ischemia (e.g., fever, leukocytosis, tachycardia, metabolic acidosis, or evidence of ischemia on imaging) or if the obstruction fails to resolve after 3 days of nonoperative management [2,12].

The risk of recurrence of adhesive small bowel obstruction is higher in patients who are managed nonoperatively compared to those who undergo surgical management, with recurrence rates ranging from 13% to 29% over long-term follow-up periods. The risk of recurrence also increases with the number of prior SBO episodes [13-15].

References

1. Rami Reddy SR, Cappell MS. A Systematic Review of the Clinical Presentation, Diagnosis, and Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep. 2017 Jun;19(6):28. doi: 10.1007/s11894-017-0566-9.

2. van Veen T, Ramanathan P, Ramsey L, Dort J, Tabello D. Predictive factors for operative intervention and ideal length of non-operative trial in adhesive small bowel obstruction. Surg Endosc. 2023 Nov;37(11):8628-8635. doi: 10.1007/s00464-023-10282-9.

3. Scaglione M, Galluzzo M, Santucci D, Trinci M, Messina L, Laccetti E, Faiella E, Beomonte Zobel B. Small bowel obstruction and intestinal ischemia: emphasizing the role of MDCT in the management decision process. Abdom Radiol (NY). 2022 May;47(5):1541-1555. doi: 10.1007/s00261-020-02800-3.

4. Miller G, Boman J, Shrier I, Gordon PH. Etiology of small bowel obstruction. Am J Surg. 2000 Jul;180(1):33-6. doi: 10.1016/s0002-9610(00)00407-4.

5. Expert Panel on Gastrointestinal Imaging; Chang KJ, Marin D, Kim DH, Fowler KJ, Camacho MA, Cash BD, Garcia EM, Hatten BW, Kambadakone AR, Levy AD, Liu PS, Moreno C, Peterson CM, Pietryga JA, Siegel A, Weinstein S, Carucci LR. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. J Am Coll Radiol. 2020 May;17(5S):S305-S314. doi: 10.1016/j.jacr.2020.01.025.

6. Jackson P, Vigiola Cruz M. Intestinal Obstruction: Evaluation and Management. Am Fam Physician. 2018 Sep 15;98(6):362-367.

7. Tanaka K, Hanyu N, Iida T, Watanabe A, Kawano S, Usuba T, Iino T, Mizuno R. Lactate levels in the detection of preoperative bowel strangulation. Am Surg. 2012 Jan;78(1):86-8.

8. Ambe PC, Kang K, Papadakis M, Zirngibl H. Can the Preoperative Serum Lactate Level Predict the Extent of Bowel Ischemia in Patients Presenting to the Emergency Department with Acute Mesenteric Ischemia? Biomed Res Int. 2017;2017:8038796. doi: 10.1155/2017/8038796.

9. Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med. 2018 Feb;36(2):234-242. doi: 10.1016/j.ajem.2017.07.085.

10. Shokoohi H, Mayes KD, Peksa GD, Loesche MA, Becker BA, Boniface KS, Lahham S, Jang TB, Secko M, Gottlieb M. Multi-center analysis of point-of-care ultrasound for small bowel obstruction: A systematic review and individual patient-level meta-analysis. Am J Emerg Med. 2023 Aug;70:144-150. doi: 10.1016/j.ajem.2023.05.039.

11. Damewood S, Finberg M, Lin-Martore M. Gastrointestinal and Biliary Point-of-Care Ultrasound. Emerg Med Clin North Am. 2024 Nov;42(4):773-790. doi: 10.1016/j.emc.2024.05.006.

12. Azagury D, Liu RC, Morgan A, Spain DA. Small bowel obstruction: A practical step-by-step evidence-based approach to evaluation, decision making, and management. J Trauma Acute Care Surg. 2015 Oct;79(4):661-8. doi: 10.1097/TA.0000000000000824.

13. Behman R, Nathens AB, Mason S, Byrne JP, Hong NL, Pechlivanoglou P, Karanicolas P. Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With the Risk of Recurrence. JAMA Surg. 2019 May 1;154(5):413-420. doi: 10.1001/jamasurg.2018.5248.

14. Medvecz AJ, Dennis BM, Wang L, Lindsell CJ, Guillamondegui OD. Impact of Operative Management on Recurrence of Adhesive Small Bowel Obstruction: A Longitudinal Analysis of a Statewide Database. J Am Coll Surg. 2020 Apr;230(4):544-551.e1. doi: 10.1016/j.jamcollsurg.2019.12.006.

15. Fevang BT, Fevang J, Lie SA, Søreide O, Svanes K, Viste A. Long-term prognosis after operation for adhesive small bowel obstruction. Ann Surg. 2004 Aug;240(2):193-201. doi: 10.1097/01.sla.0000132988.50122.de.

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Case 49: ARDS

Kayhon Rabbani

A 22 year old male who has no past medical history presented with a 3 day history of viral URI-like symptoms with sore throat, dry cough, shortness of breath, and dyspnea on exertion. The patient was an active marine recruit with many other members in his company being sick during this time. Shortly prior to arrival, the patient became unable to walk short flights of steps without becoming short of breath. The patient otherwise had no respiratory or cardiac history. He had no family history of sudden cardiac death or early MI. The patient denied fevers, chills, chest pain, pleuritic chest pain, positional chest pain, abdominal pain, flank pain, dysuria, hematuria, diarrhea, or any other associated symptoms.

Vitals: BP 87/56 | Pulse 96  | Temp 98.6 °F (37 °C)  | Resp 28 | SpO2 92%

On physical examination, the patient was alert and in acute distress. Patient presented with tachycardia, hypotension, hypoxia, and tachypnea. Mucous membranes were dry. Respiratory exam revealed decreased air movement, breath sounds, and faint crackles in the right lower lung field.

A bedside echocardiogram was performed.

Figure 1: POCUS echocardiogram in 4 chamber apical view demonstrating a small pericardial effusion.

Figure 2: POCUS lung exam revealed bilateral B lines anterosuperior aspects of the lungs.

Figure 3: Lung consolidation and pleural effusion demonstrating positive "spine sign."

The patient was initially stable but desaturated upon position change. The patient was persistently hypoxic with significant work of breathing on BiPAP before escalating to intubation, remaining persistently hypoxic in the mid 80s post intubation on a ventilator.

Discussion

Acute respiratory distress syndrome (ARDS) is a severe form of acute respiratory failure characterized by rapid onset of widespread inflammation in the lungs. It is defined by the Berlin criteria, which include acute onset within one week of a known clinical insult, bilateral opacities on chest imaging not fully explained by cardiac failure or fluid overload, and severe hypoxemia with a PaO2/FiO2 ratio of less than 300 mmHg.[1-3]

Common differential diagnoses for ARDS include cardiogenic pulmonary edema, pneumonia, and pulmonary embolism. Cardiogenic pulmonary edema can be differentiated by the presence of signs of fluid overload and cardiac dysfunction, often confirmed by echocardiography. Pneumonia may present with localized infiltrates and clinical signs of infection, while pulmonary embolism typically presents with sudden onset dyspnea, pleuritic chest pain, and may be confirmed by imaging studies such as CT pulmonary angiography.[1][4-5]

On physical examination, patients with ARDS often present with tachypnea, dyspnea, and diffuse crackles on auscultation. Hypoxemia is a hallmark, and patients may exhibit signs of respiratory distress such as use of accessory muscles and cyanosis. Imaging studies, particularly chest radiography, typically reveal bilateral alveolar infiltrates. Computed tomography (CT) scans can provide more detailed images, showing patchy or diffuse ground-glass opacities and consolidations.[1-2][6]

Point-of-care ultrasound (POCUS) is a valuable tool in the diagnosis and management of ARDS. Lung ultrasound findings in ARDS include the presence of multiple B-lines (indicating interstitial syndrome), spared areas, pleural line thickening, and subpleural consolidations. Cardiac ultrasound can help differentiate ARDS from cardiogenic pulmonary edema by assessing left ventricular function and the presence of pleural effusions.[7] Combining lung and cardiac ultrasound can enhance diagnostic accuracy and guide management decisions in critically ill patients with acute hypoxemic respiratory failure.[7]

References

  1. Saguil, A., & Fargo, M. V. (2020). Acute Respiratory Distress Syndrome: Diagnosis and Management. American family physician, 101(12), 730–738.
  2. Meyer, N. J., Gattinoni, L., & Calfee, C. S. (2021). Acute respiratory distress syndrome. Lancet (London, England), 398(10300), 622–637. https://doi.org/10.1016/S0140-6736(21)00439-6
  3. Matthay, M. A., Zemans, R. L., Zimmerman, G. A., Arabi, Y. M., Beitler, J. R., Mercat, A., Herridge, M., Randolph, A. G., & Calfee, C. S. (2019). Acute respiratory distress syndrome. Nature reviews. Disease primers, 5(1), 18. https://doi.org/10.1038/s41572-019-0069-0
  4. Papazian, L., Calfee, C. S., Chiumello, D., Luyt, C. E., Meyer, N. J., Sekiguchi, H., Matthay, M. A., & Meduri, G. U. (2016). Diagnostic workup for ARDS patients. Intensive care medicine, 42(5), 674–685. https://doi.org/10.1007/s00134-016-4324-5
  5. Sekiguchi, H., Schenck, L. A., Horie, R., Suzuki, J., Lee, E. H., McMenomy, B. P., Chen, T. E., Lekah, A., Mankad, S. V., & Gajic, O. (2015). Critical care ultrasonography differentiates ARDS, pulmonary edema, and other causes in the early course of acute hypoxemic respiratory failure. Chest, 148(4), 912–918. https://doi.org/10.1378/chest.15-0341
  6. Zompatori, M., Ciccarese, F., & Fasano, L. (2014). Overview of current lung imaging in acute respiratory distress syndrome. European respiratory review : an official journal of the European Respiratory Society, 23(134), 519–530. https://doi.org/10.1183/09059180.00001314
  7. Corradi, F., Brusasco, C., & Pelosi, P. (2014). Chest ultrasound in acute respiratory distress syndrome. Current opinion in critical care, 20(1), 98–103. https://doi.org/10.1097/MCC.0000000000000042
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Case 48: The Gut Feeling Was Right

Kanchi Mehta

A 38yo male with history of diverticulitis complicated by sepsis presented to the ED with lower quadrant abdominal pain. He noted that the pain started 2 weeks ago and became worse. He reported normal bowel movements in the morning, denied fever/chills, nausea, vomiting, or genitourinary symptoms. A recent colonoscopy was notable for moderate sigmoid diverticulosis and a 4mm sessile sigmoid polyp that was resected.

Past medical history: Diverticulitis, ADHD, eczema, insomnia, loose stools

No past surgical history.

Vitals: BP 107/65 | Pulse 73 | Temp 98 °F (36.7 °C) | Resp 18 | BMI 25.35 kg/m²

A bedside ultrasound was performed, and the following image was obtained:

Figure 1: Diverticula with bowel wall edema

Uncomplicated acute diverticulitis characteristics on ultrasound are:

  • thickened bowel wall >5mm
  • presence of diverticula with focal outpouching or bowel wall discontinuity
  • noncompressible pericolic fat inflammation with hyperechogenic halo around bowel serosa
  • sonographic tenderness with compression

Outcome:

General surgery was consulted for possible surgical evaluation, which was deferred after findings on CT noted to be non-surgical. Patient was sent home with ciprofloxacin 500mg BID for 7 days and metronidazole 500mg TID for 7 days. Patient was also educated on return precautions.

References:

  1. Nazerian P, Gigli C, Donnarumma E, et al. Diagnostic accuracy of point-of-care ultrasound integrated into clinical examination for acute diverticulitis: a prospective multicenter study. Ultraschall der Med 2021;42(6):614–22. English.
  2. Cohen A, Li T, Stankard B, et al. A prospective evaluation of point of care ultrasonographic diagnosis of diverticulitis in the emergency department. Ann Emerg Med 2020;76(6):757–66.
  3. Damewood, Sara et al. “Gastrointestinal and Biliary Point-of-Care Ultrasound.” Emergency medicine clinics of North America vol. 42,4 (2024): 773-790. doi:10.1016/j.emc.2024.05.006
  4. https://www.ultrasoundcases.info/cases/abdomen-and-retroperitoneum/gastrointestinal-tract/diverticulosis-and-diverticulitis/
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