Presenter Disclosure Information The following relationships exist related to this presentation:

10:45–11:45am

► Keith Barron, MD, has no financial relationships to disclose. ► Richard Hoppmann, MD, FACP, has no financial relationships to disclose. ► Victor Rao, MD, MBBS, DMRD, RDMS, has no financial relationships to disclose. ► Michael Wagner, MD, has no financial relationships to disclose.

Introduction to Ultrasound and Case Presentations SPEAKERS Keith Barron, MD Richard Hoppmann, MD, FACP Victor Rao, MD MBBS, DMRD, RDMS Michael Wagner, MD

Off-Label/Investigational Discussion ► In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations.

Ultrasound Cases

Right Upper Quadrant Pain Victor Rao

History

Physical Exam

 49 yrs. old Caucasian female presented with H/O pain and discomfort for 3 hours in the right upper quadrant radiating to the right scapula region following a fatty meal  No H/O fever  H/O intolerance to fatty foods for past 1 year  Prior H/O nausea (off and on) for past 10 months  No H/O prior hospitalization  No H/O clay colored stools or jaundice  PMH: No significant PMH

 Temp 98.4 F, BP 130/80 mmHg  Obese lady with no obvious distress  Alert and well oriented  No jaundice  Minimal right upper quadrant tenderness  Murphy’s sign negative  No other positive physical finding

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Lab Findings

Differential Diagnosis  Biliary Disease

 WBC count 9000 BUN, creatinine, glucose, AST, ALT, GGT, bilirubin, alkaline phosphatase and serum amylase were normal  Urine ordinary – No WBC or RBCs

     

Clinical Question

 Cholelithiasis  Acute cholecystitis  Chronic cholecystitis  CBD calculus  Cholangitis Inflamed duodenal ulcer or perforation of duodenal ulcer Renal colic Pancreatitis Pleuritic pain with or without right lower lobe pneumonia Liver pathology (hepatitis, liver abscess etc.) Acute appendicitis (rarely in this location)

Ultrasound For RUQ Pain  Patient Preparation  Ideally fasting - to distend the gallbladder and biliary tree adequately for optimal visualization  In emergency situation- scan can be performed without patient preparation

Does the patient have cholelithiasis or not?

 Transducer Selection  Low frequency curvilinear transducer 1.5-5.0 MHz

Patient Position  Supine, left lateral decubitus and upright

Ultrasound (Diagnostic Image)

Ultrasound Report No dilatation of the biliary system, CBD = 5 mm Gallbladder distended with no evidence of wall thickening Single mobile 15 mm gallstone Ultrasound Murphy’s sign – Negative No free fluid seen in abdominal cavity No hydronephrosis or renal stones No evidence of increased blood flow seen around gallbladder on color Doppler

Final Impression: CHOLELITHIASIS

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Final Diagnosis and Discussion  Symptomatic Cholelithiasis  Also known as “Biliary colic”  Pain occurs due to gallstone obstructing the neck of the gallbladder or the cystic duct  Pain resolves when stone moves away from the obstruction site in the neck of GB or passes down cystic duct  Pain lasts 1-5 hours (generally)  US – shows gallstones with or without acoustic shadow  WBC count and LFT normal  Treatment recommended: Cholecystectomy

Common Ultrasound Findings

Acoustic Shadow

Sludge

Minimum diameter of calculus to cast a shadow is 3 mm

Non Functioning Contracted Gallbladder (WES)

Chronic Cholecystitis

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Pitfalls  Patient not fasting or contracted gallbladder  Did not roll patient over or did not scan upright (can miss small calculi)

“CLUE” PROTOCOL

 Air in adjacent duodenum appearing like gallstone inside lumen of gallbladder

Michael Wagner

 Poor resolution ultrasound equipment  Obese patient (more challenging to scan)  Gallbladder ultrasound is operator dependent and requires appropriate training and experience

Case Presentation

Physical Exam

58 yo Caucasian male • VS: T-99.7, HR-115, BP-146/98, RR-24, sat-93%RA

• CC: “I feel awful” (Dyspnea)

• Gen: mild respiratory distress, speaks in short sentences

• HPI: One week history of progressive SOB, DOE, fatigue,

• Head/neck: large neck, no appreciable JVD

worsened productive cough, subjective fevers, night sweats • PMH: COPD, DM2, HTN, OSA

• CV: Tachycardic, regular, distant heart sounds

• Meds: ipratropium HFA, metformin, simvastatin, lisinopril

• Pulm: course, wheezing and crackles bilaterally

• FH: +early CAD (father), +DVT (sister)

• Abd: benign, central obesity

• SH: smoker (40 pky), +ETOH (2-3 beers/day), mechanic

• Ext: venous stasis changes, pitting edema bilaterally

Differential Diagnosis

Possible Further Testing

• COPD Exacerbation

• Electrocardiogram

• Pneumonia

• Laboratory (CBC, Biomarkers [cTn, BNP, D-dimer])

• New CHF • New CAD

• Chest Radiography

• Pleural Effusion

• Echocardiogram

• Pulmonary Embolism • Secondary Pulmonary Hypertension

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Disposition?

“CLUE” Protocol Cardiopulmonary Limited Ultrasound Exam

• “Well Doc, I’m feeling a little better after that breathing treatment….Can I just go home with some of that stuff?”

Can ultrasound increase our diagnostic abilities at the bedside? Kimura, B et al. Am J Cardiol. 2011; 108(4):586-90

Q2: Left Atrial Enlargement?

Q1: Left Ventricular Systolic Dysfunction? Normal

Defined as: Left Atrium A-P diameter > Ascending Aorta A-P diameter

Abnormal

(at the sinuses of Valsalva, throughout the cardiac cycle).

MV

IVS

IVS

Normal

MV LV

Enlarged

LA Aorta LA

Defined as: -During diastole, anterior leaflet of the mitral valve doesn’t approach the septum to within 1 cm

Pearl: If MV appears to “slap” against septum, EF likely normal.

Q4: Pulmonary Edema?

Q3: Elevated CVP/Volume Overload? Normal • Defined as: “subjectively appeared plethoric and dilated”

No Fluid (normal) Liver

RIBS

-parallel vessel walls -diameter reduction 2.5cm is generally

Fluid (abnormal) RIBS

RA

IVC Abnormal

considered enlarged

Liver RA

Pitfall: Mistaking aorta for IVC

IVC

• Predominate Horizontal (A-line) artifact pattern

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• Predominate Vertical (B-line) artifact pattern

Additional Points

References/Additional Reading

• B-Lines – Number/severity correlates with invasive measurements of lung water (1) and tracks resolution in real time in hospitalized HF patients (2)

1. Volpicelli G et al. Am J Emerg Med. 2008 Jun;26(5):585-91. 2. Agricola E et al. Chest. 2005 May;127(5):1690-5. 3. Miglioranza MH et al. JACC Cardvasc Imag. 2013 Nov;6(11):1141-51.

– Correlate with biomarkers and advanced echo measurements better than clinical congestion scores in outpatients (3)

4. Kimura, B et al. Am J Cardiol. 2011; 108(4):586-90.

– Associated with higher odds ratio for inpatient mortality: 4.6-5.3 (4)

Final Diagnosis/Conclusions • Patient with NEW Heart Failure with impaired systolic function

Leg Swelling and Redness

• CLUE allows for a “quick look” bedside ultrasound assessment that can provide the clinician with valuable information and change management decisions.

Keith R. Barron

History

Physical Exam Temp 99.9° F, P 96, BP 141/76, BMI 32 Obese man, in no distress, alert Cardiopulmonary exam unremarkable Right leg: 8x6 cm localized area of warm, circumferential, erythematous induration with a central area of marked thickening with a question of fluctuance. There is interdigital maceration of the foot.  No ulcerations, adenopathy, or crepitus (but exam limited by obesity and area is very firm)    

 63 yo white man w/ 3 days of gradually increasing right lower extremity redness, swelling, pain and warmth without discharge or drainage.  Some subjective fever and chills, but no rigors.

 No recent trauma or skin injury.  PMH: DM type II rx w/ insulin, HTN, stable PVD, 30-pack-year cigarette use

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Differential?  Cellulitis  ? Abscess

 Stasis dermatitis/acute lipodermatoscler osis  DVT  Deeper infection or osteomyelitis

US Examination • US showed extensive area of cellulitis, with a focal finding:

Must determine if cellulitis is purulent or whether drainable abscess is present to guide management and antibiotic choices

Abscess  An abscess is heterogeneously hypoechoic (darker than surrounding tissue)  Pressure may cause swirling of purulent material contained within  If cellulitis coexistent, increased hyperemia is present with absence of flow within the abscess

Diagnosis: Abscess Heterogeneous-appearing hypoechoic area

Images courtesy Paul Bornemann, MD

Image courtesy Paul Bornemann, MD

“Cobblestoning” – Finding in Cellulitis

Pitfalls – potential abscess mimics Veins

Cellulitis is indicated by hypoechoic fluid in the interlobular fissures of the subcutaneous tissues

Artery

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Normal subcutaeneous tissue

Cellulitis with cobblestoning

Treatment • Incision and drainage of abscess • Decision made to treat with antibiotics active against MRSA – Considering surrounding extensive cellulitis and comorbid conditions

Subcutaneous tissue is normally hypoechoic (darker)

In cellulitis, tissue becomes hyperechoic (brighter), with surrounding hypoechoic (darker) fluid stranding

• Follow-up ultrasound could be used to ensure complete drainage of abscess

US for Skin/Soft Tissue Infection

Abscess in the age of MRSA  22% of visits for skin/soft tissue infections are for abscess

 Without clear findings of abscess, difficult to decide on appropriate Rx  Interobserver agreement on abscess presence can be low

 Incidence is increasing yearly, with MRSA now the most common cause of abscess  MRSA largely thought to cause abscess and NOT non-purulent cellulitis

 US accurately identifies cellulitis and abscess  US use can change plans for management based on physical exam alone

 Differentiation between these entities is key – guides management

 US can ensure adequacy of drainage

 Up to 56% of patients

Pallin DJ et al. West J of Emerg Med 2014 Jan 6

Vivek et al. Acad Emerg Med. 2006; 13:384–388

Management of Skin and Soft Tissue Infections

Shoulder Pain

 If US shows no abscess, or $7B per year to treat shoulder pain

• Referred pain – cervical spine, diaphragm, heart

• Biceps tendonitis

• Inflammatory arthritis – rheumatoid, crystal disease

• Trauma / fracture / tumors / instability

Hermans J, et al. JAMA. 2013;310(8):837-847. Nazarian LN, et al. Radiology. 2013;267(2):589-595. Burbank KM, et al. Am Fam Physician. 2008;77(4):493-497. Medvecky MJ. Conn Med. 2010;74(8):457-463.

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Ultrasound of the Biceps Tendon

Value of Biceps Tendon Physical Examination Sensitivity

Specificity

Normal

Predictive Value

Yergason’s

32%

78%

49%

Tenderness

57%

72%

57%

Chen HS, et al. Ultrasound in Med & Biol. 2011;37(9):1392-1398.

Ultrasound for Shoulder Complaints • Advantages: – Low cost and portable – Great spatial resolution and dynamic examinations – Can be used to guide aspirations and injections – No contraindications and patients prefer it over MRI • Disadvantages: – Operator dependent – requires instruction and practice – Limited access to joint capsule, labrum, cartilage, and intraosseous space as compared to MRI

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Patient