Dr. Laura Weber’s Case of the Week!

HPI: The patient is an 81 y.o. female with PMH of colon cancer s/p recent colectomy who presents with dyspnea on exertion, palpitations, and left lower extremity swelling. Patient was found to be hypoxic to 89% on RA and had left leg swelling with tenderness to palpation of posterior calf.

ED US: 

The Basics:  Clots in the deep venous system of the lower extremities pose significant risk of pulmonary embolism. Major branches of the deep venous system in the lower extremity include the common femoral vein (CFV), superficial femoral vein (SFV), and popliteal vein. The CFV is formed by the deep femoral vein (DFV) and SFV. The great saphenous vein (GSV) drains into it caudally. The popliteal vein is formed by the confluence of the anterior tibial, posterior tibia, and peroneal veins. Blood clots are most likely to occur at junctions of veins. Therefore, the limited compression DVT study must include the CFV at the GSV junction to the SFV and DFV bifurcation and popliteal vein to the popliteal trifurcation.

The Protocol:
·   A high frequency vascular probe (6-10 Hz) should be used. If the patient has a lot of overlaying tissue, a lower frequency curvilinear probe can be used. The patient should be positioned in the reverse Trendelenburg position with their hip in mild external rotation and knee slightly bent. This position will maximize the distension of the leg veins.
·  Evaluation is done by compressing the veins with the probe perpendicular to the patient and assessing for complete apposition of the anterior and posterior walls of the vessels. Inability to completely compress the vein suggests a clot. The clot itself may be visible in the vein as echogenicity within the lumen.
·   Other techniques that can give further information about the patency of the vessel:

  1. Color-flow Doppler can demonstrate a lack of flow in the vessel or a filling defect.
  2. Respiratory phasicity is a technique where pulsed wave Doppler is superimposed on top of the vein to observe the respiratory variation of blood flow in the vein. A lack of normal respiratory variation may be suggestive of clot impeding flow proximal to the level evaluated.
  3. Augmentation is a technique where the provider squeezes the calf briskly below the level of suspicion while visualizing the vessel with pulse Doppler imaging. A corresponding burst represents a patent vessel. If there is no burst, it is suggestive of a completely obstructive clot distal or at the level visualized. However, studies have shown that there is a lack in clinical benefit of this technique and that it may cause unnecessary discomfort in patients.

Hospital Course: After the positive DVT study in the ED, the patient was started on anticoagulation and admitted to the ICU. The patient remained stable and was weaned off from supplemental oxygen by hospital day two and subsequently discharged by hospital day six on Eliquis.

References: 
Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014.” WikiJournal of Medicine 1(2).DOI:10.15347/wjm/2014.010. ISSN 2002-4436.

Dean, Anthony J, and Bon S Ku. “Section Links.” Deep Venous Thrombosis, ACEP, www.acep.org/sonoguide/dvt.html.

Lockhart, Mark E, et al. “Augmentation in Lower Extremity Sonography for the Detection of Deep Venous Thrombosis : American Journal of Roentgenology : Vol. 184, No. 2 (AJR).” American Journal of Roentgenology, vol. 184, no. 2, Feb. 2005, pp. 419–422., www.ajronline.org/doi/full/10.2214/ajr.184.2.01840419.

Rios , Marina Del, et al. “ACEP.” Focus On: Emergency Ultrasound For Deep Vein Thrombosis // ACEP, Mar. 2009, www.acep.org/Clinical—Practice-Management/Focus-On–Emergency-Ultrasound-For-Deep-Vein-Thrombosis/#sm.0000d1ebcfwu3dj3ycw1vqtn6irgs.

Schott, Christopher. “DVT Ultrasound: Augmentation Technique.” Critical Care Medicine DVT Ultrasonography, Sonoguide’s Critical Care Ultrasound, 21 Aug. 2013, www.youtube.com/watch?v=pjkaFr24xGw.

Dr. Pasternac’s case of the week! Check it out…

41 yo F without significant PMH, presenting with 1 day of epigastric pain associated with nausea and chills. In the ED, patient was found to have +RUQ tenderness on exam. A bedside ultrasound was performed, revealing…

 

 

 

 

 

 

a 7mm impacted stone near GB neck, in addition to…

 

 

 

 

 

 

 

a 7.7mm CBD.

+Sonographic murphy’s sign

Below is an example of cholecystitis with GB wall thickening and pericholecystic fluid.

A radiology ultrasound confirmed findings appreciated on POCUS.

The patient underwent therapeutic ERCP and was then taken to the OR the next day for an uncomplicated laparoscopic cholecystectomy.

Transabdominal RUQ US is the initial study of choice for detecting biliary pathology (quick, noninvasive, no radiation risk, cost-effective). Ultrasound has been shown to be superior to CT in identifying acute cholecystitis. The signs of acute cholecystitis on ultrasound include:

  • the presence of gallstones and/or sludge
  • a thickened anterior gallbladder wall (>3mm),
  • pericholecystic fluid, and
  • the presence of sonographic Murphy’s sign.

It is important to assess the common bile duct (CBD) during your RUQ exam, as a dilated CBD can indicate an obstructing stone in the duct, which would change management and warrant further evaluation with MRCP or ERCP. A Cochrane meta-analysis of 5 studies found a pooled sensitivity and specificity of 73% and 91%, respectively, for ultrasound detection of choledocholithiasis.  As CBD diameters can increase with age, a general rule of thumb for a normal CBD measurement is 4mm + 1mm for every decade after 40. When the CBD is the same size as the portal vein, also known as the “double barrel” or “shot gun” sign, there is cause for alarm. However, patients s/p cholecystectomy can have dilated CBDs at baseline up to 1cm. The American Society for Gastrointestinal Endoscopy has proposed a risk stratification tool to identify those patients with symptomatic cholelithiasis who may be at risk for choledocholithiasis (see Table below), which can be used in conjunction with your RUQ US. Suggested management for each risk category is shown in the associated flow chart.

 

 

Sources

ASGE Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Journal of Gastrointestinal Endoscopy.  2010;71(1):1.

Gurusamy KS, et al. Ultrasound versus liver function tests for diagnosis of common bile duct stones. Cochrane Database Syst Rev. 2015 Feb 26;(2):CD011548.

Harvey RT, Miller WT Jr. Acute biliary disease: initial CT and follow up US versus initial US and follow up CT. Radiology 1999 Dec; 213(3):831-6.

 

 

More international ultrasound education- a visit to Village Health Works in Burundi

Dr. Tim Gallagher and I recently returned from Burundi, where we had the opportunity to meet, teach (and learn from!) the providers and staff at Village Health Works in Kigutu.  We held a week-long ultrasound training session with the on-site providers.  Needless to say, we were inspired! Village Health Works is an amazing organization that is changing lives.  Take a look here- https://www.villagehealthworks.org/

Another Intern US Workshop success!

Thanks to everyone who helped share their knowledge

and expertise with the new interns yesterday for their

Introduction to Ultrasound workshop!  A special thanks

to our faculty- Steve, Uché, Kristin, Lindsey, Adriana and

our fellow Lindsay, as well as our resident ultrasound

enthusiasts- Joe, Magda, Rich, Emily and Sindhya!

 

Thanks to Dr. Kristen Ng for the 1st case of the month!…..Pregnant female + lower abdominal pain

34 year old F G4P1021, 14 weeks pregnant, presents with right lower quadrant pain x 1 day. She states that the pain began the night prior to presentation, feels like “pulling”, worse today and accompanied by difficulty walking. Has pain with movement as well as at rest. Radiates across the suprapubic area. Endorses dysuria. Denies vaginal bleeding or discharge, nausea, vomiting, or diarrhea. Last bowel movement was earlier today and was non-bloody. Denies abdominal surgeries in the past.

Ultrasound examination to confirm IUP and FHR, as well as identify other abdominal pathology like appendicitis, yielded the following:

 

 

 

 

 

 

 

 

Ultrasound visualization of a mass coming off of the right uterine body measuring approximately 5cm x 7cm, with mild peripheral edematous changes suggestive of a torsed pedunculated fibroid is visualized. A normal right ovary is seen posterior to the pedunculated fibroid. These findings were confirmed with MRI.

Torsed fibroids do not require acute surgical intervention, nor do they endanger the fetus by their presence. Management consists mainly of symptom control. The patient was given acetaminophen and oxycodone with improvement of symptoms. She will follow up with obstetrics within 48 hours for re-evaluation.

And we’re back! An official welcome to our new fellows!


Lindsay Davis joins us from Hudson, OH. She graduated from Duke University undergrad. Afterward, she danced professionally with the Cincinnati Ballet Company, then worked in public health at the Cleveland Clinic. She completed her medical training and residency at Temple University School of Medicine/Temple University Hospital in Philadelphia, PA!

 

Di Coneybeare is one of our own! She just finished her residency here at NYU/Bellevue and is staying on for a two-year combined US fellowship and Masters in Health Education. She is originally from Portlandia, then transplanted to New York for medical school and residency. She enjoys exploring the city (especially the food scene), playing with her dogs and seeking out green spaces.