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IOTW 11/23/20

67 y/o F p/w RUQ pain

  1. What are the three structures that compose the portal triad?
    • Portal vein, hepatic artery, and common bile duct. The common bile duct will not exhibit flow when evaluated with color doppler.
  2. Which structure is indicated by label “A”?
    • The common bile duct. Note the absence of flow with color doppler.
  3. What is the name of the artifact indicated by label “B”?
    • Acoustic shadowing. Ultrasound waves are absorbed by a solid structure or reflected off of air, causing “clean” or “dirty” shadowing, respectively.
  4. What is the normal diameter of structure “A”? What about if the patient is post-cholecystectomy?
    • The CBD should measure <6 mm in diameter and the upper limit increases by 1 mm per decade after age 60. Post-cholecystectomy CBD may measure up to 10 mm (1 cm) in diameter. Be sure to measure from inner wall to opposing inner wall in a perpendicular fashion.
  5. What is the diagnosis hinted at by label “C”?
    • Choledocholithiasis. The CBD is grossly enlarged and measures about 9-10 mm in diameter when compared with the scale on the right-hand side of the screen. Label “C” indicates a visualized stone within the CBD distally which appears as an echogenic rounded focus with shadowing.
  6. Do these images suggest the presence of concomitant acute cholecystitis?
    • No. Sonographic evidence of cholecystitis includes stone in neck (SIN sign), anterior gallbladder wall thickening, pericholecystic fluid, gallbladder hydrops, and sonographic Murphy’s sign, none of which are present. There are numerous small gallstones within the gallbladder, however, which should at least raise suspicion for other biliary tract obstruction.
  7. Which diagnosis would you be most concerned about if the patient exhibited signs of infection?
    • Ascending cholangitis. The classic Charcot’s Triad (fever + jaundice + RUQ pain) only occurs in ~50% of patients and the classic Reynold’s Pentad (triad + altered mental status + hypotension) only occurs in <5%. In elderly patients, hypotension may sometimes be the only presenting sign, so a high index of suspicion must be maintained. If the diagnosis is likely, patients should be treated aggressively for sepsis with fluid resuscitation and antibiotics targeted at organisms such as E. coli, Enterococcus, Bacteroides, Clostridium, and even MRSA in severe cases. The case should be coordinated with gastroenterology and general surgery for ERCP and cholecystectomy to achieve source control and biliary decompression.

IOTW 11/10/20

28M p/w biliary colic however reports PMHx of “dilated heart”. Bedside ECHO was performed…

  1. What are some EKG findings associated with the suspected diagnosis?
    • In the setting of hypertrophic cardiomyopathy, EKGs may often be nonspecific or normal. However, you may see a high voltage or LVH pattern and deep narrow “needle-like” Q waves in the inferolateral leads. There may also be deep T-wave inversions in the anterolateral leads.
  2. What LV wall thickness supports the diagnosis?
    • Unexplained wall thickness >1.5 cm in any myocardial segment. A septal:posterior wall thickness ratio can be measured. An abnormal ratio is >1.3 in normotensive patients and >1.5 in hypertensive patients. The ratio in the image above comes out to (3.1 cm/1.8 cm=) ~1.7 which is abnormal and should prompt further evaluation. Asymmetric septal hypertrophy may be present. In addition, the LV outflow tract diameter can be measured in the parasternal long view just proximal to the aortic valve to assess for obstruction. The LVOT normally measures 1.6 – 2.4 cm.
  3. What features of the mitral valve are associated with this?
    • Mitral regurgitation is sometimes present. You may also assess for systolic anterior motion (SAM) of the mitral valve to help assess for obstruction. To do this you would obtain an M-Mode waveform through the anterior mitral valve leaflet in parasternal long view similar to how you would assess for EPSS. The mitral valve would exhibit anterior excursion toward the interventricular septum during systole if this was present.
  4. If this patient presents in decompensated CHF, what are some considerations in the management in regards to…
    • Administering IV fluids?
      • Volume loading is essential to increase preload and you should be sure to adequately fluid resuscitate prior to considering pressors in order to avoid worsening of the LV outflow tract obstruction. Monitor carefully for signs of fluid overload.
    • Intubation?
      • If it is absolutely necessary and cannot be avoided, you want to take all precautions to maintain preload. Push dose phenylephrine should be mixed and readily available (1 mL of 10 mg/mL phenylephrine in 100 mL NS = 100 mcg/mL; may use 1-2 mL (100-200 mcg) q2-5 min). BVM ventilations should not be aggressively performed. Avoid high airway pressures.
    • Managing tachycardia?
      • Beta blockers are the mainstay especially if angina or dyspnea present. You can titrate to a resting heart rate of 60 bpm. Use with caution if there is sinus bradycardia or conduction abnormality. Verapamil is another option. You must avoid vasodilators such as nitrates and dihydropyridine CCBs such as nifedipine. Do not give digitalis. Have a low threshold to cardiovert if needed to maintain sinus rhythm, for example if there is atrial fibrillation.
    • Choice of vasopressors?
      • If hypotensive and decision is made to initiate pressors, goal is to increase afterload. Phenylephrine is probably the best pressor to start with and consider vasopressin if it is maxed and a second pressor is needed. To increase efficacy of your pressors, attempt to fix any acidosis if present. AVOID positive intotropes such as dobutamine, norepinephrine, epinephrine, and dopamine.
  5. What is the definitive treatment of this condition?
    • While an ICD +/- AV sequential pacing may be used to treat ventricular dysrhythmias, the definitive treatment of LV outflow tract obstruction is myomectomy or resection of outflow tract.
  6. If the patient cannot be admitted, what discharge instructions should be provided?
    • Important to avoid exertion. May be started on beta-blocker from ED while pending cardiology appointment and follow-up comprehensive echo.

IOTW 11/02/20

38 y/o F p/w RUQ pain

  1. Does this gallbladder contain gallstones?
    • Yes. Although gallstones are not seen on this CT, they are easily visualized on the ultrasound (see image below answers) Only 74-79% of stones are identified on CT scan. Typically they are only seen on CT if they are calcified, whereas cholesterol stones and others may be hypoattenuating or isodense to bile, rendering them non-distinguishable. Ultrasound is considered the gold standard for detecting gallstones which can identify stones as small as 2 mm with a sensitivity of greater than 95%.
  2. Which label (A, B, or C) is the most accurate GB wall measurement and is it abnormal?
    • A is the most accurate measurement in this image corresponding to a wall thickness of approximately 1.8 cm. Wall >4 mm (with some sources even stating 3 mm) is considered abnormal. Label B may be tempting to select, however this only measures from the inner wall to a region of wall edema, which would lead to a greatly under-measured wall. Label C measures the posterior wall, which would falsely enhance the measurement due to the artifact posterior acoustic enhancement. Due to this artifact, only the anterior gallbladder wall should ever be measured when performing biliary ultrasound.
  3. Is this a contracted gallbladder or is there wall edema? How does the sonographic appearance of these differ?
    • This is gallbladder wall edema. Note the irregular anechoic and hypoechoic areas within the wall. A contracted gallbladder will show pseudothickening which tends to form a more symmetric and diffuse pattern. Wall edema may be focal or more diffuse with irregular areas demonstrating various echogenicities. (See images below answers)
  4. What is represented by label D?
    • Pericholecystic fluid. It can often be subtle, so be sure to have a keen eye.
  5. Are these images overall consistent with cholecystitis?
    • Yes. Gallbladder wall thickening and pericholecystic fluid are secondary findings of cholecystitis and have a low specificity alone. The presence of gallstones with wall thickening, however, has been shown to have a positive predictive value of >95% for cholecystitis.
Gallstones. Note the hyperechoic rims with shadowing posteriorly
Contracted gallbladder on left exhibiting pseudothickening. Gallbladder wall edema on right.


IOTW 10/20/20

54M p/w left eye curtain-down vision loss preceded by 5 days of flashes and floaters

  1. What structure is indicated by label “A”?
    • Eyelid. To perform this study, copious gel is placed over the patient’s eye while their eyelid is closed. Thus the first structure seen nearest the footprint is the eyelid.
  2. What structure is indicated by label “B”?
    • Cornea.
  3. What structure is indicated by label “C”?
    • Iris and ciliary bodies.
  4. What is indicated by label “D”?
    • Pupil.
  5. What structure is indicated by label “E”?
    • Posterior capsule of the lens.
  6. What chamber is located between labels “B” and “C”?
    • Anterior chamber. The anterior segment is located between the cornea and lens. The anterior chamber of the anterior segment is located between the cornea and iris. The posterior chamber of the anterior segment is located between the iris and lens. These are both filled with aqueous humor.
  7. What chamber is indicated by label “F”?
    • Vitreous chamber. This is also known as the posterior segment.
  8. What structure is indicated by label “G”?
    • Optic nerve within optic nerve sheath.
  9. What is the diagnosis indicated by label “H”?
    • Retinal detachment (with some vitreous debris).
      • Your primary differential for a hyperechoic curvilinear structure running along the edge within the vitreous chamber is: posterior vitreous detachment, retinal detachment, or choroid detachment.
      • The vitreous layer is the innermost of these 3 layers. When detached, it is often fairly thin (best visualized with high gain settings), can be seen crossing the macula, and is mobile with oculokinetic movements.
      • The retina is located between the vitreous and choroid layers. When detached, it can be visualized inserting into the macula at the optic disk and is also mobile with oculokinetic movements.
      • The choroid is located between the retina and sclera. When detached, it appears as a thick echogenic pair of bands that remain fixed with oculokinetic movements.
  10. BONUS: What is being measured in the final image and what diagnosis does this exclude?
    • Presence of arterial flow over the central retinal artery. When a patient presents with symptoms concerning for amaurosis fugax, central retinal artery occlusion should be highly considered on your differential. Presence of adequate arterial flow over the central retinal artery excludes this diagnosis. .

IOTW 10/13/2020

36 y/o M p/w R scrotal pain

  1. What is the hyperechoic linear structure labeled “A”?
    • Mediastinum testis of the right testicle. It is a network of fibrous connective tissue formed by invagination of the tunica and not a pathologic finding.
  2. What is the hyperechoic structure labeled “B” in the images above?
    • Epididymal head. It is normally isoechoic or mildly hyperechoic compared to the testicle echotexture. It is located near the superior pole of the testicle. The epididymal body (not visualized) extends down the posterior aspect of the testicle leading to the epididymal tail (not visualized) near the inferior pole of the testicle which becomes the proximal ductus deferens.
  3. What is the layer labeled “C”?
    • Tunica albuginea. It is a fibrous covering of the testis and is best visualized in the presence of fluid.
  4. What is the layer labeled “D”?
    • Visceral layer of the tunica vaginalis. It is a serous membrane covering the testis.
  5. What is the layer labeled “E”?
    • Parietal layer of the tunica vaginalis. This layer is normally held tightly against the visceral layer however becomes separated in the presence of hydrocele.
  6. How would you describe the fluid collection indicated by “F”?
    • Complex hydrocele. Note the subtle layering of debris. Hydroceles form between the layers of the tunica vaginalis and may be congenital or acquired. They are normally anechoic and simple unless complicated by infection or hemorrhage.
  7. Does the presence of normal vascular flow rule out testicular torsion? In females, does the presence of normal vascular flow rule out ovarian torsion?
    • The presence of normal flow rules out testicular torsion in males at the time of the ultrasound examination. The presence of flow, however, DOES NOT rule out ovarian torsion in females. The sole blood supply to the testicle is the testicular artery, whereas the ovaries have dual blood supply from primarily the ovarian arteries with collateral flow from the uterine arteries. Be aware that in the case of intermittent testicular torsion and detorsion, testicular flow may be increased and appear hyperemic, making it difficult to distinguish from orchitis. Thus, a proper history and physical exam are extremely important.
  8. What is the most likely diagnosis in this case?
    • Right-sided epididymo-orchitis. Notice the more hyperechoic appearance and hypervascularity of the right epididymis and testicle when compared to the left. Management is targeted at treating sexually transmitted infections and/or enteric organisms depending on age and risk factors. Patients should follow-up with urology in 1 week if they do not meet admission criteria.