IOTW 9/17/2020

55M w/ hx of L ureteral stent p/w abdominal pain and dysuria

  1. How would you grade the level of hydronephrosis in A?
    • Moderate hydronephrosis.
    • Explanation: Mild hydronephrosis is dilatation of the renal pelvis. In higher grade cases of mild hydronephrosis, the dilatation may begin to involve the calyces. Moderate hydronephrosis is when the calyces become so dilated that they obtain a rounded appearance called the “Bear Paw Sign”. Severe hydronephrosis is when there is cortical thinning and loss of borders between the ballooned renal pelvis and calyces.
  2. What other positive finding do you see in A?
    • Nephrolithiasis. There is an intraparenchymal stone at the right-most calyx. Notice the shadow artifact.
  3. What positive finding do you see in B?
    • There is a ureter stone. Again, notice the shadowing.
  4. What finding regarding the bladder do you notice in C?
    • There is a large bladder stone. This was actually found to be obstructing the ureterovesical junction.

IOTW 8/31/2020

57F p/w epigastric pain with RUQ ttp on exam

  1. What is the name of this ultrasound finding?
  • Wall Echo Shadow (WES) sign

2. What is the etiology of this finding?

  • Large gallstone or numerous smaller gallstones filling the lumen of a contracted gallbladder

3. What are three things that should be on
your differential when you see this?

  • Air-filled bowel loop, porcelain gallbladder, emphysematous cholecystitis

4. Is this finding a sign of cholecystitis?

  • No. The five sonographic signs of cholecystitis are: stone impaction in neck, anterior wall thickening, pericholecystic fluid, gallbladder hydrops, and sonographic Murphy sign

WES sign is non-specific, so if acute cholecystitis is suspected,
CT or HIDA scan may be appropriate

IOTW 08-17-2020


26 y/o male presents with abdominal pain and emesis. RLQ POCUS performed as below.

What do you think?


  • What is the diagnosis? Acute appendicitis without rupture
  • What are the sonographic landmarks
    for performing this exam?
    RLQ and point of maximal tenderness; must visualize iliac vessels and psoas muscle
  • What are the sonographic “hard” signs
    of a positive exam?
    Non-compressible, non-peristaltic, avascular blind-ended tubular structure traceable to cecum measuring >6 mm
  • What are the sonographic “soft” signs? Appendicolith, RLQ free fluid, periappendiceal fat stranding (increased echogenicity), “Ring of Fire” (increased peripheral vascularity), enlarged mesenteric lymph nodes

Note that appendix may be compressible if it is ruptured!

IOTW 01-01-18

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Powerpoint –> IOTW 1-1-18


  • 36 yo F presents to ED for abdominal pain. Abdominal pain is located in the RUQ and LLQ. Associated with one episode of diarrhea in the morning and emesis.
  • ED team requested a RUQ sono to assess for biliary pathology
  • During the exam, the patient asked “ Can you look here where it’s REALLY hurting?” and pointed to LLQ





Small Bowel Obstruction On Ultrasound?


Criteria of SBO

  • dilated bowel loop (diameter > 2.5 cm)
  • bowel wall thickening > 3mm
  • fluid-filled distended bowel with extra luminal free fluid between bowel loops
  • Back and forth peristalsis
  • May see transition point


What happened to the patient:

  • Patient was found to have an SBO on CT scan. She went to the OR for an emergent ex-lap and was found to have frank pus in her abdomen without any signs of perforation.