December SonoProps
Well come all to the holiday season!
The first SonoProps goes to our very own Dr. Obioma Nkemakolam!
He did this ultrasound on a 13-year-old male who was complaining of left lower quadrant pain and left testicular pain.
Buddy view of both testicles.
What do you suspect is the diagnosis?
If you suspected left testicular torsion, you would be correct! The patient was taken to the OR and and had a detorsion and orchipexy and is doing well currently.
Learning points:
Testicular ultrasound may seem daunting at first but torsion is something that can quickly be evaluated for using POCUS, especially when absent flow is noted. Trained emergency physician performed POCUS of the scrotum has a very high sensitivity and specificity. This is especially valuable if ultrasound is not available 24/7 or is delayed. 50% of patients with testicular torsion delay seeking care for greater than 6 hours and are at high risk of losing the torsed testicle so anything that can be done to avoid delaying care should be carried out.
Using a linear probe, first obtain a “buddy view,” that includes both testicles as in the first clip.
Evaluate for echotexture and lie of the testicles and note if the affected testicle appears different. Adjust gain and then do not change throughout scan. In this case, the left testicle is more heterogenous and appears slightly enlarged. Edema and change in echotexure may take up to 6 hours to develop.
Evaluate the unaffected testicle using color doppler or power doppler, make sure it is on “low” flow and set the gain high enough to get baseline flow in the unaffected testicle. Baseline arterial and venous spectral doppler measurements should be obtained (advanced).
Evaluate the affected testicle using color doppler or power doppler. If there is no flow, you have ruled in testicular torsion with very high sensitivity. Noting a twisted spermatic cord as in clip 2 above, further aids in solidying the diagnosis. Manual detorsion may be attempted and a re-evaluation for flow can be performed.
If flow is present in the affected testicle, arterial and venous spectral doppler waveforms should be obtained. The presence of color/power doppler alone does not rule out torsion. Furthermore, even with spectral doppler, the presence of arterial flow alone does not rule out torsion as venous flow is the first to be affected. Absent venous flow may be the only finding in early torsion. Clinical correlation is key!
Great scan Dr. Nkemakolam!
The next SonoProps also goes to one of our residents Dr. Yanel Maher!
Dr. Maher had a 42-year-old patient who noted that her eyes were getting yellow and her abdomen was getting slightly distended. So he did what any excellent resident would do and grabbed the ultrasound and saved his images. This is what he saw:
This patient has an excellent example of diffuse gallbladder wall edema. Edema is slightly different from thickening in that it is possible to visualize some separating portions of the wall due to the underlying subserosal edema.
There is also notable anechoic fluid present near the liver in the second clip indicating ascites, rather than pericholecystic fluid. Not visualized was the enlarged liver that extended far beyond the kidney.
Looking at the pelvis, there was significantly more ascites, however it was noted it was behind the bladder and uterus without a safe window for paracentesis.
Diagnosis: Acute liver failure with new onset ascites from chronic alcohol abuse
Learning points:
Gallbladder wall edema is a non-specific finding that may occur in a multitude of pathologies. The mechanism for developing edema not due to lithiasis is not well known but suspected to occur due to elevated portal venous pressure, increased systemic venous pressure, decreased osmotic intravascular pressure, increased vascular permeability, or any combination of these.
It can be sign of acute or chronic cholecystitis, however it can be present in:
Liver pathologies including: cirrhosis, hepatitis
Generalized edematous states: congestive heart failure, hypoalbuminemia, nephrotic syndrome
Ascites
Extra-cholecystic inflammation: pancreatitis, pyelonephritis, peritonitis, perforated duodenal ulcers
Some viral infections: mononucleosis, dengue, HIV/AIDS
Malignancy / gallbladder carcinoma
Some things to help you differentiate whether the edema is from cholecystitis or not are the presence of other signs of cholecystitis such as sonographic Murphy’s sign, which is highly specific for cholecystitis. This patient did not have a sonographic Murphy’s sign and had findings more consistent with acute liver failure and ascites.
Again, POCUS does not live in a bubble, it is a vital procedure that is performed by you to answer questions and clinical correlation is key!
Good scan Dr. Maher!
