September SonoProps
Our first September SonoProps goes to Dr. Yanel Maher. It is always an immense pleasure when your trainee becomes good enough to come up to you and let you know they found interesting pathology on a scan and they are correct.
Dr. Maher on one of his scan shifts, was scanning a patient and saw this on his right lower quadrant evaluation.
Can you guess what he saw?
Dr. Maher immediately recognized the patient had acute appendicitis! We notified surgery right away and the patient was admitted to the surgical service after a CT scan.
See the attached clip for a great example of a positive appendicitis scan. This patient also had some reactive free fluid.
Learning points:
Appendicitis is one of the tougher diagnosis to make sonographically, especially in adults, due to the varying positions of the appendix. If your appendicitis scan is negative but your suspicion is high, obtain further imaging (CT, MRI). However, when the appendix IS visualized and dilated the specificity is high.
The landmarks include the psoas muscle and the iliac vessels, although you can also ask the patient where they are most tender and start scanning there.
Appendicitis can be identified by visualizing the presence of a blind-ended, dilated, non-compressible, aperistaltic structure that measures greater than 0.8cm (some textbooks say 0.6cm, we use 0.8cm) and can be traced back to the cecum. An appendicolith may be visualized. You may also notice peri-appendiceal fat inflammatory changes (bright white fat around the appendix), reactive free fluid, and hyperemia on color doppler.
In the clip the cecum is the dome shaped structure that comes into view on the left hand side.
Great scan Dr. Maher!
The second SonoProps this month is also going to one of our residents, Dr. Andrew Weinberger! Dr. Weinberger did this excellent scan and provides a great learning image.
A 16-year-old male with right flank pain was scanned.
Dr. Weinberger noted that the patient had mild to moderate right hydronephrosis with a ~5mm UVJ stone.
Learning points:
A renal scan is performed to evaluate for hydronephrosis, not necessarily to look for the stone itself. Hydronephrosis can be graded mild, moderate, severe.
You may sometimes get very lucky and catch the stone at the UVJ (or UPJ). When visualized using color doppler a stone creates an artifact known as a "twinkle" artifact due to the irregularities on the surface of the stone interacting with the color doppler signals creating a very confused rainbow/twinkling signature.
This patient also has ureteral jets present. Most people normally have about 2 or more ureteral jets per minute. Although too long to perform in the emergency department - for educational purposes absence of ureteral jets after 10 minutes of observation may indicate a complete obstruction, and ureteral jet frequency less than 2 jets per minute may indicate partial obstruction. There is no need to look for ureteral jets in the emergency department, the practical utility is not well established.
Great scan Dr. Weinberger.
