"Well hellllllo there...I'm so ASCITED to see you!"
Patient with ascites and a surprising greeting on POCUS.
Dr. Stephen Alerhand Mount Sinai Hospital
Small Bowel Obstruction
This image demonstrates a dilated loop of small bowel with to and fro movements of stool contents. POCUS has been shown to have a sensitivity of 0.91 and specificity of 0.84 for this indication in a single trial when EM residents performed the study. This is compared to 0.02 and 0.67 for an old fashioned KUB.
Jang TB, et al. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. J Emerg Med. 2011. 28(8):676-678.
Dr. Justin Bowra et al.
80 y/o demented M patient comes in with complaint of abdominal distention, noticed by care givers. Patient "not keeping anything down." POCUS was done to visualize the "distention." Fluid is seen in what was presumably the stomach, moving forward and backward, not passing the pylorus. The distal bowel did not contain similar fluid. CT demonstrated gastric volvulus and GI was consulted.
Dr. Bryan Jarret - Kings County/SUNY Downstate Emergency Medicine
A Case of Colicky Abdominal Pain
This is a transverse view of the right upper quadrant of an infant who presented with several days of worsening colicky pain. He had decreased appetite, activity and vomiting. Bedside ultrasound revealed evidence of intussusception with extensive surrounding bowel edema likely secondary to delayed presentation.
Chris Heberer, DO EM PGY-3
Biliary Colic That Wasn't
This is an image from a 55 years gentleman with suspected biliary colic. A gallstone was confirmed however the patient's symptoms during exam did not match classic biliary colic. A more in depth evaluation of the right upper quadrant confirmed the presence of right colonic mass. Color flow was appreciated on a separate clip. Although bowel pathologies are an uncommon finding at emergency ultrasound, they can be easily found with further investigation in atypical presentations.
Stefanie Tamburrini, MD
Reducing Aspiration Risk
A 76 year old female ward patient was vomiting and in respiratory distress possibly due to aspiration. The patient is impending respiratory failure and the plan was to intubate and admit to ICU. A POCUS was done to evaluate her distended abdomen prior to intubation and the image demonstrated a grossly distended stomach with swirling hyperechoic particles. NG tube was placed and approximately 1 liter of bilious fluid was removed. Patient was safely intubated thereafter with aspiration risk minimized.
For peri-intubation patient with distended abdomen or with high aspiration risk, a quick POCUS can help determine the amount of gastric content and potentially alter management to include maneuvers to minimize aspiration risk. This has been studied in anesthesia literature and is routinely performed by Dr. Paul Mayo’s critical care team at Northwell LIJ.
Van de Putte P, Perlas A. Ultrasound assessment of gastric content and volume. Br J Anaesth. 2014 Jul;113(1):12-22. doi: 10.1093/bja/aeu151.
POCUS image acquired and contributed by: Leon Chen, NP – Critical Care Medicine Service Department of Anesthesiology and Critical Care Medicine Memorial Sloan Kettering Cancer Center New York, NY Adjunct Clinical Faculty NYU Rory Meyer College of Nursing New York, NY
Intussusception is typically a disease of the young, 6 months to 6 years but it can occur in adults. In adults they will ofter present similar to bowel obstructions, with vomiting, constipation, and rectal bleeding. Ultrasound can still be used to work them up although most of the time CT will be used first.
In kids, the operating characteristics approach 100% sensitivity and specificity but can be operator dependent. It is usually performed with a linear probe in children but in this image, a curvilinear probe was used.
Justin Bowra MBBS, FACEM, CCPU Emergency Physician, RNSH et al.
Enlarged Appendix with Appendicolith
This images demonstrates a longitudinal view of an appendix that appears enlarged with edematous walls, containing a shadowing appendicolith, consistent with acute appendicitis.
- Dr. Justin Bowra et al.
The Piano Sign
A 55 year old male came to ED c/o abdomen pain for 3 days associated with abdominal distention and vomiting. He was noted to be tachycardic and his abdominal exam demonstrated tenderness and bulging in the right inguinal area.
A curvilinear probe was used to evaluate for bowel obstruction. The clip demonstrates a dilated loop of bowel, "to and fro" movements of bowel content suggesting dysfunctional peristalsis, and the piano sign. The piano sign (or keyboard sign) is essentially visualization of the plicae circularis which is associated with the diagnosis of small bowel obstruction.
Dr. Mahmoud S Alsomali
EM Resident R4; Saudi Board Of Emergency Medicine; King Saud Medical City; Riyadh KSA
30 y/o F with chills, constipation for 3 days. Normal labs and vitals, but distinctly tender in the RLQ. POCUS performed revealed free fluid and surrounding bowel walled edema with a structure floating that is likely the appendix.
CT confirms a perforated appendix with trace free air complex fluid and thickening of adjacent bowel wall.
Dr’s Sophia Sharifali, Esther Kwak, and John F Kilpatrick -