A 76-year-old male with a history of coronary artery disease presents with 3 months of abdominal pain. Patient first experienced nausea, vomiting, diarrhea, chills, and severe right lower quadrant abdominal pain approximately 3 months ago. Patient states the pain improved after several days of rest, a bland diet, and hydration. However, patient reported continued decreased appetite and weight loss of 15-20 pounds over the intervening months. The pain recurred approximately one month ago and did not improve with rest prompting patient to see his primary care physician. Patient was placed on oral amoxicillin–clavulanate and instructed to get a CT scan of the abdomen and pelvis. Patient presented to the emergency department following the CT. Vitals include BP 122/69, HR 60, SpO2 98% on RA, T 97.8F. Patient is well appearing with mild tenderness to palpation in the right lower quadrant.

An ultrasound is performed and shown below. What’s the diagnosis? How is the ultrasound performed? What else should you be considering given this patient’s history?

Answer: Appendicitis

Appendicitis Ultrasound:

Technique

• Probe – Linear probe often works best. Can consider curvilinear probe in those with larger body habitus.
• 1) Ask patient to point area of maximal tenderness and place linear probe on this area
• 2) Apply steady but gradually increasing pressure in this area to displace bowel gas and enable visualization
• 3) Appendix is typically anterior to psoas and iliac vessels and is a blind tubular structure that has no peristalsis
• 4) If not visualized over area of maximal tenderness can track up and down along iliac vessels to look for appendix

Pathologic findings

• 1) Dilation > 6 mm in transverse diameter
• 2) Non-compressible
• 3) May have surrounding edema and fecalith within the appendix

Appendicitis Ultrasound Pearls:

• Appendix can be hard to visualize due to body habitus, bowel gas, or because it is retrocecal. Tips to improve visualization:
  • Have patient place right leg crossed over left
  • Roll patient into left lateral decubitus
• Appendix can be hard to differentiate from terminal ileum
  • Terminal ileum does not have a blind ending
  • Terminal ileum will show peristalsis
• Always make sure to visualize the blind ending of the appendix
• Ultrasound “Rules In” appendicitis!

Patient ultimately taken to OR by surgery where appendix was removed and sent to pathology. Given patients presentation of chronic appendicitis couple with weight loss there was concern for appendiceal cancer. Pathology has not returned at this time.

Appendiceal Cancer Facts:

• Cancer of the appendix is observed in <2% of appendiceal specimens
• Most patients are asymptomatic but in those who experience symptoms 30% present with acute appendicitis
• History that should raise suspicion for appendiceal cancer include
  • Appendicitis in a patient >50 yrs of age
  • Chronic symptoms of appendicitis
  • Weight loss and anorexia

References:

https://coreultrasound.com/appendicitis/

Uya, A., & Chaiaza, H. (2021, June 24). Appendicitis. ACEP Symbol. https://www.acep.org/sonoguide/advanced/appendicitis

Osueni A, Chowdhury YS. Appendix Cancer. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555943/

A 62 year old male presents to the ED with 1 week of abdominal distension with associated nausea and vomiting. He has had only 2 small bowel movements in the last week. He denies abdominal pain. On exam, his abdomen is distended and rigid. An obstruction series is obtained and shown below. What’s the diagnosis?

Answer: multiple air-fluid levels concerning for obstruction

• CT A/P obtained (shown below) – diagnosis of Large bowel obstruction
• Most common cause of large bowel obstruction = neoplasm/mass
  • Other causes: diverticulitis, sigmoid or cecal volvulus
  • Other uncommon causes: adhesions, hernias, IBS, fecal impaction, intraluminal FB, intussusception
• LBO are less common than SBO
• Presenting sypmtoms: abdominal pain/distension, constipation
• CT A/P w/ IV contrast is imaging modality of choice
• Most require surgery
• Ogilvie Syndrome: acute colonic psuedo-obstruction due to loss of sympathetic innervation of colon (no actual mechanical obstruction)
  • Usually seen in severely ill patients with multiple comorbidities
  • CT shows marked dilatation of the large bowel without any evidence of a marked transition point or obstructing lesion

References:
Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic radiographic and CT findings, etiology and mimics. Radiology. 2015 June;275(3):651-63.

Price TG, Orthober RJ. Bowel Obstruction. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 538-41

Case: A 60 year old female with a past medical history of a left hip replacement presents with a chief complaint of left hip pain after a fall. Since the fall she has been unable to move her hip and on exam the left leg is visibly shortened, adducted, and internally rotated, otherwise the patient is neurovascularly intact. X-ray reveals the image below. What’s the diagnosis?

Answer: Posterior Hip Dislocation

Case Continued: Under procedural sedation with keto-fol the hip was reduced successfully using the Captain Morgan technique as demonstrated in post-reduction XRs below. The patient was then placed in a knee immobilizer and discharged with an abduction pillow and orthopedic follow up.

• Over 90% of hip dislocations are posterior
• Up to 10% of prosthetic hips undergo dislocation with the vast majority being posterior
• Native hip dislocations are an orthopedic emergency and should be reduced as soon as possible!
  • The risk of avascular necrosis increases from <10% to about 25%  when reduction is extended from 10 hours to 15 hours
  • Prosthetic hip dislocation is not as time sensitive as there is no blood flow to the joint, thus no risk of avascular necrosis.
  • Sciatic nerve injury can occur in both native and prosthetic posterior hip dislocations
• There are many different reduction techniques including but not limited to:
  • Captain Morgan: https://www.youtube.com/watch?v=lQMWaFX-MeQ 
  • Whistler technique: https://www.youtube.com/watch?v=Fl71ztyFU7I 
  • Allis technique: https://www.youtube.com/watch?v=eMVsjwAukU4 
  • Below is a comprehensive guide to multiple different techniques:
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229/ 
• A CT should be obtained post-reduction of native hips to rule out fractures/loose debris

Resources:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations#v35074190

Tintinalli’s Emergency Medicine Cases A comprehensive Study Guide 9th Edition, Judith Tintinalli

A 30 year old female with a history of IV drug use presents with 2 weeks of progressively worsening right sided pleuritic chest pain, productive cough, and shortness of breath.  A chest x-ray is shown below. What’s the diagnosis?

Answer: Cavitary lesion with air-fluid level consistent with abscess from septic emboli secondary to infective endocarditis

Etiology: Bacteria laden clots from right sided bacterial endocarditis, septic thrombophlebitis, periodontal, and central venous catheter infections. In IVDU, the tricuspid valve is most commonly involved with the most common pathogen being Staph aureus

Presentation: Pleuritic chest pain, cough, fever, hemoptysis

Differential for lung abscesses: Septic emboli, Tuberculosis, Aspergillosis, Granulomatosis with Polyangitis, Sarcoidosis, malignancy

Diagnosis: Chest x-ray, CT chest, blood cultures, echocardiogram

Treatment: Typically 2-8 weeks of IV antibiotics with possible abscess drainage +/- heart valve replacement

References:

Stawicki SP, Firstenberg MS, Lyaker MR, et al. Septic embolism in the intensive care unit. Int JCrit Illn Inj Sci. 2013;3(1):58-63. doi:10.4103/2229-5151.109423

Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. J Belg Soc Radiol.2016;100(1):100. Published 2016 Nov 19. doi:10.5334/jbr-btr.1202