A 58 year old woman presented with a chief complaint of epigastric abdominal pain for the past 6 months.  Her PMHx was significant for hypertension, and she had been evaluated with a colonoscopy and EGD 2 months prior to presentation.  Her medications included Altace and Atenolol.
VS: T 98.9 P 80 BP 200/120 R 16 O2 sat 98% on RA.

A RUQ ultrasound was done to assess the gallbladder:

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Figure 1: A mid-range frequency, phased array probe is used to assess the gallbladder in its long axis.

Figure 2: A dilated common bile duct is seen here. Note that a “normal” measurement for the CBD is considered to be less than 6mm; some providers allow 1 mm per decade. A patient who is s/p cholecystectomy may have a CBD that is dilated up to 1 cm.

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Figure 3: In this view we see the gallbladder in short axis. We see peristaltic movement of bowel to the right of the gallbladder, but pay attention to the hypoechoic area seen within the liver tissue to the left of the gallbladder.

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Figure 4: Upon closer inspection of the liver, we see multiple heterogeneous areas suspicious for metastatic disease.

The patient went for ERCP, and a pancreatic mass was noted. The incidental findings in the hepatic tissue were noted on QA, or quality assurance review, highlighting the importance of not only noting the area intended for exam, but also the surrounding tissue as normal or abnormal. “Incidentalomas” may be frequently identified when examining the RUQ on ultrasound; in one report a nonbiliary source of pain was identified in 21% of cases (1). Although specific characterization of these findings is often outside the scope of emergency ultrasound, EUS serves as a reasonable first line screening modality for identification of RUQ pathology.

1. Shuman WP, Mack LA, Rudd TG, et al. Evaluation of acute right upper quadrant pain: sonography and 99m-Tc-PIPIDA cholescintigraphy. AJR Am J Roentgenol. 1982; 139:61-64.

Recommended reading: Leeuwen MV, Nederend J, Smithuis R. What to do with incidentally found lesions in the liver? Radiology department of the University Medical Centre of Utrecht, the Leiden University and the Rijnland Hospital, Leiderdorp, the Netherlands

View link here: www.radiologyassistant.nl/en/45a5e818c709d

Figure 1: Free fluid seen in RUQ

Figure 2: Free fluid seen in LUQ

Figure 3: Free fluid seen in pelvis on TV ultrasound

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Figure 3: Grossly positive FAST exam with free fluid in the LUQ

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Figure 4: Free fluid seen around R adnexa

Given these findings, a pregnancy test was performed and found to be positive. OB/GYN was consulted and emergently took the patient to the OR where laparoscopic exploration revealed a tubal pregnancy. The patient underwent salpingectomy and recovered succesfully. In the case of undifferentiated hypotension in a young woman, ectopic pregnancy is high on the differential. A 2008 study published in Academic Emergency Medicine demonstrated a significant correlation between the presence of free fluid in Morrison’s pouch on FAST exam and the need for definitive operative management in the setting of extrauterine pregnancy (1). The average time of the scans in this study was less than five minutes, demonstrating potential to significantly decrease ER to OR time in the setting of an unstable patient requiring operative intervention.

Recommended reading: (1) Moore C, Todd W, O’Brien E, et al. Free Fluid in Morison’s Pouch on Bedside Ultrasound Predicts Need for Operative Intervention in Suspected Ectopic Pregnancy. Academic Emergency Medicine 2008; 14(8):755-758.

Figure 1: RUQ with no free fluid seen on FAST exam

The LUQ and pelvis were also negative for free fluid or noted abnormalities. A four chamber view of the heart performed as part of the FAST exam is shown below:

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Figure 2: Apical 4-chamber view of the heart

Note the presence of a hyperechoic mass-like structure in the right atrium; concerning for thrombus vs. mass. Cardiology was then consulted and a complete TTE was done in ED confirming the presence of an atrial mass.  The patient was  admitted for further work-up, where a CT of the chest revealed a 4 cm filling defect in the right atrium concerning for a myxoma. The CT also revealed what appeared to be lytic lesions in the spine.  The patient was found to be HIV positive, and on hospital day 5 underwent radical resection of the right atrium, described as a spindle cell carcinoma on the initial pathology report. The final report from Johns Hopkins pathology revealed grade 3 Angiosarcoma.

Cardiac tumors are uncommon, usually benign myxomas, although lipomas and fibromas may occur.  Rare primary malignant tumors include sarcomas (especially angiosarcoma), as well as mesotheliomas and lymphoma.  Metastatic tumors and venous extension (renal, adrenal, and liver cancer) may also involve the heart.  Myxomas usually attach to interatrial septum on the left, and are slow growing masses that often present with embolic phenomenon.  Surgery is curative in most cases; 5% recur.  Angiosarcomas typically involve the pericardium and left atrium, and may cause obstruction with signs and symptoms of R sided heart failure.  Surgery is the mainstay of therapy, combined with radiation, chemo, and immunotherapy.  Mean survival for most primary cardiac sarcomas is less than 1 year.

The practitioners in this case imaged the heart as part of the FAST exam and were able to identify this extremely unusual pathology.  And while they were not initially suspicious of a cardiac etiology of his symtoms, their use of an alternative imaging modality provided important information about the underlying cause of the patient’s symptoms.  This case highlights the fact that the presence of persistent symptoms in the face of recent negative imaging should prompt a re-evaluation of the patient’s complaint.

Recommended reading: Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med. 2003; 10: 1054-1058.

Special thanks to Dr. Ali Pourmand and Dr. Pete Dowiatt for their excellent clinical care and scanning skills!

A 22 year old female G6P6 presented with abdominal pain and discomfort for four weeks.  Past medical history was significant for three cesarean sections. She had undergone IUD insertion one year ago for purposes of birth control.  She took no medicines, and was allergic to penicillin.

Physical Exam:
Gen: WD/WN/WH, mildly anxious
HEENT: NC/AT, PERRLA, EOMI,
CV: RRR, no M/R/G
Lungs: CTA bilaterally
Abd: Soft, NT/ND, no masses, no HSM, mildly TTP at suprapubic abdomen, L>R
Ext: no C/C/E, equal bilateral pedal pulses

Labs:
WBC:  5.6
H/H: 12.6/ 36.0
Platelets:  220
Na: 137
K: 4.2
Cl: 112
HCO3: 24
BUN: 12
Cr: 1.2

While a urine pregnancy test was pending, the physician performed a transabdominal ultrasound:

Figure 1: Longitudinal still shot of the uterus demonstrating an IUP with FHR at 167. Nrml FHR generally ranges from 120-160.

Figure 2: Using the OB presets on the machine allows measurement of the crown rump length and estimates of gestational age.

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Figure 3: This transverse view of uterus demonstrates the IUP. Watch for the bright, “T”-shapes object which appears as the operator scans through the uterus in the last 2 seconds of the clip.

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Figure 4: The green arrow on this longitudinal view of the uterus demonstrates the presence of the IUD.

Intrauterine devices have until recently been considered a poor choice of birth control for nulliparous women due to a concern for increased rates of PID and subsequent increased risk for ectopic pregnancy.  In 1974, the CDC raised questions about the Dalkon Shield, an IUD marketed between 1970 and 1974, and found an excess risk of complicated pregnancies among the Dalkon Shield users compared with users of other IUDs. The manufacturer withdrew the device from the market in 1974. While this device is still more commonly placed in multips, the IUD is now considered safe for all women as a pregnancy prevention device provided there is no increased risk of exposure to STDs. In the United States there are two commercially available IUDs: a copper device which may be left in place for 10 years,  and a hormonal device which must be replaced every five years. While the presence of an IUD alone does not confer an increased risk of ectopic pregnancy, pregnancies which occur with an IUD in place (failure rate < 1% in first year) are more likely to be ectopic. The presence of an IUD with an intrauterine pregnancy is usually grounds for removal as the presence of the IUD may cause complications with the developing pregnancy.

Recommended reading: Nagamani P, Graham D, Levine D. Imaging of intrauterine contraceptive devices. Journal of ultrasound medicine, 2007. 26: 1389-1401. 

Special thanks to Dr.  Kerri Layman for her scanning skills and excellent clinical care!

A 65 year old male with a history of DM, A-fib, and HTN with a recent CABG 8 months prior was sent to the emergency department from his primary care doctor’s office for “I&D of an abscess”.  The patient had visited the office with a chief complaint of pain, swelling, and erythema at the medial aspect of his anterior upper thigh. The patient was febrile with a temperature of 38.5, pulse of 98, BP 158/98, RR 12 at 98% on RA. Physical exam revealed a well nourished, well hydrated gentleman with clear lungs, irregularly irregular heart sounds with no murmurs, and a soft abdomen with active bowel sounds and no tenderness or masses. His extremities were warm and well perfused and 2+ bilateral DP and PT pulses were noted.  On his left anterior thigh in the groin region a 4″x4″ erythemetous area was noted with a palpable 2″X2″ fluctuate mass.  Bedside ultrasound of the area revealed the following:

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Figure 1: A 13-6 MHz transducer (vascular probe) is used to obtain these images of the soft tissue of the patients thigh, directly over the femoral vessels. In this view the structure are oriented in transverse view, and we see what appears to be pulsatile flow directly beneath the area of warmth and erythema previously intended for I&D.

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Figure 2: Upon closer inspection of the pulsatile mass we see swirling, bidirectional or “yin-yang” color flow in the lumen.

Conclusion: Procedure-related vascular injuries often follow percutaneous procedures, and include perivascular hematomas, pseudoaneurysms, and AV fistulas.  A pseudoaneurysm is a pulsatile hematoma contained within the surrounding tissues that communicates with the artery and represents injury to all three layers of the arterial wall.  Pseudoaneurysms complicate 0.1-0.2% of diagnostic and 3.5-5.5% of interventional procedures, and represent the majority of interventional vascular complications (1). On clinical exam a pulsatile mass is noted with a palpable thrill, and color duplex sonography demonstrates the turbulent, bidirectional flow seen in figure 2.  The treatment of choice is sonographically guided thrombin injection, which will thrombose the pseudoaneurysm in seconds with a 93-100% success rate (2,3). A void of flow after injection confirms success.

1. Kronzon I. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysm: a review. J Am Soc Echocardioagraphy 1997; 10:236-245

2. Morgan R, Belli A. Current treatment methods for post-catheterization pseudoaneurysms. J Vasc Interv Radiol 2003; 14:697-710.

3. Brophy DP, Sheiman RG, Amatulle P, Akbari CM. Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression. Radiology 2000; 214: 278-282.

Recommended reading: Gaitini D, Razi N, Ghersin E, et al. Sonographic Evaluation of Vascular injuries. Journal of Ultrasound Medicine 2008; 27:95-107.

Special thanks to Dr. Kirsten Bendeck for her scanning skills and excellent clinical care!