EUS Challenging Cases 20110623

88F with SOB

CC: SOB for 3 days with PND and orthopnea PE:
Bilateral and diffuse rales and wheezing Bilateral legs edema

Lab:
BNP 1820 pg/ml

ECHO

CXR
20110609 20110613-ER

Dx: CHF with APE EUS

Bilateral lung rockets No pericardial effusion No right chamber dilatation Dilated left heart with poor contraction and engorged IVC

72F with RLQ abdominal pain

CC: RLQ pain for 2 days PE:
RLQ tenderness Rebound tenderness Muscle guarding

Lab:
WBC 14200 (S 83) CRP 12

Dx: Ruptured Appendicitis EUS

Identify anatomy landmarks Cecum/ Ileum/ Appendix Appendicitis rupture Direct OP without other imaging

45F with abdominal pain

CC:
abdominal pain for 3 days Accompanied by vomiting and diarrhea Worsening pain for one day

PE:
Diffuse low abdominal tenderness RLQ pain > LLQ muscle guarding

ECHO

CT

Dx: Appendicitis EUS

Landmark Cecum/ Ileum/ Appendix/ Iliac vessels/ Psoas muscle Enlarged appendix with dirty fluid

21M with RLQ pain

CC: RLQ pain for half day PE: RLQ tenderness with muscle guarding

ECHO

CT

Dx: Cecal diverticulitis EUS

Cecal wall edema with visible IC valve Fecalith Dome sign

68M with epigastric pain

CC: epigastric pain for several days PE:
Icteric sclera Epigastric tenderness No peritoneal sign

Lab: T. bilirubin 4.9; WBC 8200 ECHO

CT

CT

Dx: Cholangiocarcinoma EUS

Bilateral IHD dilatation Antler sign Echogenic content within biliary duct

83F with abdominal pain and vomit

CC: RUQ pain with vomiting PE: RUQ mass with tenderness

ECHO

CT

Adenocarcinoma with intussusception

Dx: Intussusception caused by colon cancer EUS

Colon scanning technique Hay Fork sign

55F with LLQ pain

CC:
LLQ pain for one day OPD referred for r/o ureteral stone

PE:
LLQ tenderness with local muscle guarding

ECHO

CT

DX: Epiploic appendagitis EUS

Echogenic fat along intact colon Tender and non-compressible

29F, fell from 4 F

CC: falling injury from 4F with pre-hospital arrest and ROSC s/p EMT resuscitation PE: multiple injury with profound shock ECHO

CT

Dx: Liver laceration with hemoperitoneum EUS

Liver laceration with irregularly hypodense echotexture Exclude PTX ( not shown) Ascites over paracolic gutter and CDS Cant identify all injury

30F with RLQ pain for 2 days

CC:
RLQ pain for 2 days with fever and anorexia s/p appendectomy 12 days earlier

PE: RLQ tenderness with guarding ECHO

CT

Dx: Intra-abdominal abscess EUS

Extraluminal hypoechoic collection Echogenic fat

55M with left abdominal pain

CC: left abdominal pain for 5 days PE:
Left mid-abdominal tenderness with guarding

ECHO

CT

Dx: Intra-abdominal abscess EUS

Hypoechoic collection Hyperechoic mesenteric fat Ascites

4M boy with abdominal pain

CC: intermittent abdominal cramping with increased frequency PE: RUQ tenderness w/o peritoneal sign

Hx: frequent intussusception

ECHO

Dx: Intussusception EUS

Target and pseudo-kidney sign RUQ location Ileocolic type

79M with epigastralgia

CC:
79M with epigastralgia for one day Intermittent abdominal discomfort for half month Recent history of liver abscess and s/p cholecystitis

PE:
Icteric sclera Epigastric tenderness without peritoneal sign

ECHO

CT

Dx: liver abscess & biliary obstruction EUS

Liver abscess Biliary dilatation (Bil. IHD and MBD) Echogenic content

85M found collapse at home

CC: LOC during feeding PE: OHCA

ECHO

ECG 1

ECG 2

Dx: OHCA / AMI as cause EUS

No pericardial effusion No right chamber dilatation Parasternal long/short axis & Apical four chamber view Asymmetric LV contraction

53M with left abdominal pain

CC: left abdominal pain with dysuria PE:
left flank knocking tenderness left abdominal tenderness no peritoneal sign

Lab: urinalysis: RBC 51-100/hpf; Cr 1.9

KUB/ ECHO

Dx: Ureteral stone w/ obstructive uropathy EUS

Left renal stone Left severe hydronephrosis & hydroureter Left ureteral stones Note associated landmarks

60M with RLQ pain

CC: RLQ pain for 3 hours PE: RLQ tenderness

Lab: U/A RBC > 100 / hpf

ECHO

KUB

Dx: Ureteral stone w/ obstructive uropathy EUS

Obstructive uropathy Ureteral echogenic lesion w/ shadow Search hydroureter along psoas muscle

78M with left flank pain

CC: left flank pain for 4 hours PE:
left flank knocking tenderness LLQ tenderness

Lab:
U/A: WBC > 100/hpf; RBC > 100/hpf

KUB/ EUS

Dx: Ureteral stone w/ obstructive uropathy EUS

HCC s/p TAE Left obstructive uropathy Renal and ureteral stones UV duct / Psoas muscle/ Iliac vessels

53M with right flank pain

CC: right flank and abdominal pain for 2 hours PE: right flank knocking tenderness ECHO

Dx: Right ureteral stone EUS

Begin from transverse scan along psoas muscle Dilated ureter and stone with shadow

73F with left leg pain

CC: left leg pain for 3 days with worsening redness and swelling PE: red, tender & swollen left leg ECHO

Dx: DVT EUS

Two-point compression Total collapse exclude DVT Echogenic thrombus

79M with SOB

CC:
productive cough for 2 weeks SOB and poor appetite for 3 days

PE: left basal crackles and decreased BS Lab:

PLE Glu <2; LDH 7530

ECHO

CT

Dx: Empyema EUS

Septation Echogenic pleural effusion Consolidation Air bronchogram Assisted thoracentesis

92F with right thigh swelling

CC: right thigh swelling and ecchymosis for 3 d PE: right thigh ecchymosis and swelling ECHO

CT

Dx: Femoral pseudoaneurysm rupure EUS

Pulsatile mass with echogenic turbulent flow

19F with abdominal pain post MBA

CC:
motorcyclist suffered from traffic accident Left shoulder and abdominal pain

PE:
Left abdominal tenderness with guarding No hypotension

ECHO 1; 2

CT

Dx: Splenic laceration with hemoperitoneum

Ascites on FAST Left splenic upper pole heterogenous echotexture