"Abscessed" with Bowel POCUS: Diverticulitis

HPI: 42 yo male with no PMH presenting for abdominal pain x 2 days. His physical exam was significant for LLQ tenderness with guarding and rebound.

POCUS showed (see video):

We initially thought the outpouching connected to the abscess was a diverticulum but on further review, it’s more likely to be a loop of bowel given its size.

What a diverticulum should look like:

CT scan for reference:

Diagnosing Diverticulitis on POCUS

• Use curvilinear vs linear probe

• Start at maximal point of pain > lawnmower technique

• #1: Find diverticula

• Looks like outpouching attached to loop of bowel

• Secondary findings:

• Bowel wall diameter >5 mm

• Prominent, fluid-filled bowel loops

• Pericolic fluid collections

• Increased pericolic fat (hyperechoic fat anterior to diverticula)

• Intraabdominal abscesses

Case conclusion: CTAP showed perforated diverticulitis with multiple intraabdominal abscess. Patient was taken for IR drainage with feculent/purulent drainage noted. Patient is still doing well on surgical service.

References

1. https://coreultrasound.com/diverticulitis/

2. https://www.ultrasoundgel.org/posts/SFPsfN9yJ-9uSp640QlWtg

3. https://www.ultrasoundcases.info/diverticulosis---diverticulitis-531/

VOTW: Small Bowel Obstruction

HPI: 60 yo male with PMH of cerebral palsy, hx of SBO s/p resection and PEG tube presented to ED for vomiting. 

POCUS showed:

Note the to and fro peristalsis. Usually bowel is not visualized this well on POCUS due to air artifact. This, in itself, is a sign of surrounding edema and fluid filled structures.

Note that this is small bowel because of the “keyboard” sign representing plicae circulares (vs haustra seen in large bowel)

SBO POCUS findings:

1. 3 dilated small bowel loops >2.5 cm

2. To and fro peristalsis

3. Bowel wall edema >3 mm

4. Free fluid (previously known as “tanga sign”)

Case conclusion: Patient was admitted to surgical service for management of SBO!

Happy Scanning!

• The US Team

VOTW: Interscalene Block for Shoulder Dislocation Reduction

This week’s VOTW is brought to you by the US Team Drs. Jennie Xu and Laura Gonzalez and ED team Drs. Jennifer Wolin and Daniel Evans!

HPI: 45 year old male with no PMH presenting for left shoulder pain after falling off his scooter today. He was found to have an anterior shoulder dislocation and luckily the US team was available for an interscalene nerve block to help with pain control and an easier shoulder reduction!

Supplies you’ll need

Chlorhexidine

US probe cover

Echogenic needle

Sterile flush

10 mL of 1-2% lidocaine with or without epi (short acting anesthetic because it’s just for the shoulder reduction and has the potential to cause diaphragm paralysis- remember C3-5 innervates the diaphragm).

Place your linear probe at the medial/anterior neck at the level of the cricoid cartilage. Visualize the “stoplight” between the anterior and middle scalene muscles. The stoplight represents C5-7 in the brachial plexus.

Advance your echogenic needle through the prevertebral fascia and continue to bath the nerves (C5-7) with lidocaine. Use your saline flush to make sure you are in the right fascial plane prior to injecting your lidocaine.

Case conclusion: The ED team easily and quickly were able to reduce the patient’s shoulder dislocation!

Happy Scanning!

• The US Team

References

1. https://highlandultrasound.com/interscalene-block