A 45yo male presented with generalized abdominal pain and vomiting. He had no focal tenderness to palpation on examination. He had three bowel movements on the day of presentation. This point-of-care ultrasound demonstrated a dilated fluid-filled stomach which raised concern for a small bowel obstruction:

Ultrasound assessment of the stomach to gauge aspiration risk or for diagnostic purposes can be performed using a low-frequency transducer with the indicator directed cephalad over the epigastric region or the left mid-axillary line fanning anterior to the spleen. The differential for a fluid-filled stomach includes gastro-intestinal bleeding, small bowel obstruction, or gastroparesis.

While there is extensive literature on the test characteristics of ultrasound for small bowel obstruction, there is still limited data on stomach dilatation. To assess aspiration risk, anesthesiologists assess perioperatively, obstetricians assess women during and after pregnancy, and it has been compared to “fasting time” among pediatric patients. Case reports in emergency medicine have illustrated the value of gastric PoCUS to diagnose volvulus as well as confirmation of nasogastric tube placement.

References:

Lin YC, Yu YC, Huang YT, Wu YY, Wang TC, Huang WC, Yang MD, Hsu YP. Diagnostic accuracy of ultrasound for small bowel obstruction: A systematic review and meta-analysis. Eur J Radiol. 2021 Mar;136:109565. doi: 10.1016/j.ejrad.2021.109565. Epub 2021 Jan 23. PMID: 33516142.

Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. Am J Emerg Med. 2018 Feb;36(2):234-242. doi: 10.1016/j.ajem.2017.07.085. Epub 2017 Jul 29. PMID: 28797559.

Perlas A, Arzola C, Van de Putte P. Point-of-care gastric ultrasound and aspiration risk assessment: a narrative review. Can J Anaesth. 2018 Apr;65(4):437-448. English. doi: 10.1007/s12630-017-1031-9. Epub 2017 Dec 11. PMID: 29230709.

Howle R, Sultan P, Shah R, Sceales P, Van de Putte P, Bampoe S. Gastric point-of-care ultrasound (PoCUS) during pregnancy and the postpartum period: a systematic review. Int J Obstet Anesth. 2020 Nov;44:24-32. doi: 10.1016/j.ijoa.2020.05.005. Epub 2020 May 29. PMID: 32693329.

Miller AF, Levy JA, Krauss BS, Gravel CA, Vieira RL, Neuman MI, Monuteaux MC, Rempell RG. Does Point-of-Care Gastric Ultrasound Correlate With Reported Fasting Time? Pediatr Emerg Care. 2021 Dec 1;37(12):e1265-e1269. doi: 10.1097/PEC.0000000000001997. PMID: 31913246.

Kitai Y, Sato R, Inoue T. Gastric volvulus suspected by POCUS finding in the emergency department. BMJ Case Rep. 2022 Aug 19;15(8):e250659. doi: 10.1136/bcr-2022-250659. PMID: 35985747; PMCID: PMC9396154.

Shokraneh K, Johnson J, Cabrera G, Kalivoda EJ. Emergency Physician-Performed Bedside Ultrasound of Gastric Volvulus. Cureus. 2020 Aug 22;12(8):e9946. doi: 10.7759/cureus.9946. PMID: 32968605; PMCID: PMC7505670.

Yaseen M, Kumar A, Bhoi S, Sinha TP, Jamshed N, Aggarwal P, Murmu LR, Ekka M. Point-of-care ultrasonography-assisted nasogastric tube placement in the emergency department: a randomized controlled trial. Eur J Emerg Med. 2022 Jul 14. doi: 10.1097/MEJ.0000000000000962. Epub ahead of print. PMID: 35834792.

A healthy 12-month-old boy presented to the ED with fever. Fever is a common complaint in the ED. He was slightly tachypnea but otherwise had a normal examination (TMs clear, lungs clear, no rash, normal GU exam). A lung PoCUS exam revealed a consolidation >1cm consistent with pneumonia. Consolidation is when the usual A-line artifacts from air-filled lung are replaced with a hypoechoic tissue-like region representing pus-filled lung. When there is a mixture of air and fluid, B-lines can be seen.

Technique: A linear transducer allows higher resolution to view consolidation beneath the pleural line, whereas a lower frequency phased array transducer allows greater depth and also amplifies artifacts such as B-lines associated with pneumonia.

Accuracy: PoCUS demonstrating lung consolidation >1cm is 86% sensitive and 97% specific for community-acquired pneumonia. *When compared to chest x-ray, lung ultrasound was superior (90% vs 59% accuracy).

References:

Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr. 2013 Feb;167(2):119-25. doi: 10.1001/2013.jamapediatrics.107. PMID: 23229753.

*Ye X, Xiao H, Chen B, Zhang S. Accuracy of Lung Ultrasonography versus Chest Radiography for the Diagnosis of Adult Community-Acquired Pneumonia: Review of the Literature and Meta-Analysis. PLoS One. 2015 Jun 24;10(6):e0130066. doi: 10.1371/journal.pone.0130066. PMID: 26107512; PMCID: PMC4479467.

Free air within the peritoneal cavity results from tissue ischemia, erosion, infection, mechanical injury, or thermal injury. Perforated bowel such as from diverticulitis and peptic ulcer disease, as well as cancer, are common etiologies in the United States for this surgical emergency. Globally, typhoid fever can cause ileal perforation, especially in Africa.

Technique: with the patient in slight reverse trendelenberg (30 degrees), place a low frequency convex transducer over the anterior aspect of the liver, with the indicator directed cephalad. Free air will interpose itself between the liver and peritoneal line, appearing hyperechoic with posterior reverberation (similar to a b line or a line as you would see in the lungs, depending on the quantity of air present). Applying pressure over this area with the transducer will cause displacement of the air in real time (scissors maneuver).

Accuracy: When performed correctly by an experienced physician, ultrasound performs with 92-95% sensitivity for pneumoperitoneum (compared to 78% for radiography), detecting as little as 1 mL of air (clip above demonstrates a single bubble of air from a perforated diverticulitis). Specificity is similar to radiography.

Pitfall: Chilaiditi’s sign is a rare anomaly more common in males than females where the intestine interposes itself between the liver and right diaphragm (incidence 0.025-0.28%). It will appear as pneumoperitoneum on radiography and ultrasound.

Reference: Taylor MA, Merritt CH, Riddle PJ Jr, DeGennaro CJ, Barron KR. Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J. 2020 Dec 7;12(1):52. doi: 10.1186/s13089-020-00195-2. PMID: 33284363; PMCID: PMC7721848.

First described in 1990

Pathophysiology (still being studied): severe stress–>catecholamine release–>disruptions to the cardiac microvasculature–>vasospasm–> ballooning of the left ventricle.

• In 75% to 80% of patients, this occurs at the apex of the left ventricle, producing the classic appearance of Takotsubo cardiomyopathy reminiscent of Japanese octopus traps.

• In 10% to 20% of patients, midventricular ballooning occurs.

• In rare cases, basal, biventricular, or focal ballooning have been observed. 

• Ventricular ballooning produces transient ST-segment elevation on ECG, increased levels of troponin and B-type natriuretic protein (BNP), and a reduced ejection fraction resulting in acute systolic heart failure.

Presentation: Most patients diagnosed with Takotsubo cardiomyopathy are originally suspected to have acute coronary syndrome. About 2% of those initially suspected of having ACS are ultimately diagnosed with Takotsubo cardiomyopathy.

Diagnosis (typically made when cardiac catheterization reveals no blockage):

• Transient dyskinesis of the left ventricular midsegments, with or without apical involvement; the regional wall-motion abnormalities extend beyond a single epicardial vascular distribution, and a stressful trigger is often, but not always, present

• Absence of obstructive coronary disease or absence of angiographic evidence of acute plaque rupture

• New ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in the cardiac troponin level

• Absence of pheochromocytoma and myocarditis.

Treatment: Supportive, requires inpatient care with cardiology services. Spontaneous return of left ventricular function often occurs within 21 days of the onset of the syndrome.

Reference: Boyd, Brenton MMSc, PA-C; Solh, Tia MSPAS, PA-C Takotsubo cardiomyopathy, JAAPA: March 2020 – Volume 33 – Issue 3 – p 24-29 doi: 10.1097/01.JAA.0000654368.35241.fc

2.6-4% of patients with lower extremity deep venous thrombosis (DVT) have an IVC thrombus.

Risk Factors: IVC filter, congenital IVC anomaly, Budd-Chiari syndrome, prothrombotic factors (smoking, obesity, oral contraceptives, nephrotic syndrome, pregnancy, malignancy–especially renal cell carcinoma).

Complications: pulmonary embolism (30%), venous claudication (45%), venous ulceration (15%), lower extremity DVT (90%)

Mortality: twice as high as that of DVT

Management: Anticoagulation

Reference: Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016 Apr 11;9(7):629-43. doi: 10.1016/j.jcin.2015.12.268. Epub 2016 Mar 4. PMID: 26952909.