rady resident symposium: ultrasound · case #2: history withheld multiple shadowing stones. wall...
TRANSCRIPT
![Page 1: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/1.jpg)
RADY Resident Symposium:Ultrasound
Marie Vogel, MDJeremy Kim, MD
University of North Carolina School of MedicineDepartment of Radiology
![Page 2: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/2.jpg)
Learning objectives
By the end of this activity, participants will be able to:
I. Describe basic functions of ultrasound and common indications
II. Identify basic abdominal US anatomyIII. Recognize classic ultrasound cases
![Page 3: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/3.jpg)
Module Outline
I. Basics & IndicationsII. Abdominal US AnatomyIII. CasesIV. Wrap up/Questions
![Page 4: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/4.jpg)
Ultrasound Basics
Uses sound waves(don’t worry about the physics ... that’s my job!)
ProsReal timeNon invasivePortableNon ionizingRelatively lower cost vs CT/MRI
![Page 5: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/5.jpg)
Ultrasound Basics
ConsObese patientsCan’t see through air or bowelSmaller field of viewOperator dependentNPO for abdominal US
SafetyDoes not emit ionizing radiation BUT:
Produces heatCan make tissues ‘cavitate’
![Page 6: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/6.jpg)
Ultrasound Basics
Echogenicity - Amount of echoes an organ/structure has, ie the ability to return the signal in ultrasound examinations
A structure is echogenic if it has internal echoes, ie it is capable of reflecting sound waves. The term echogenic is used in comparison to other imaged/surrounding structures Hyperechoic - brighter
Isoechoic - same Hypoechoic - darker
Anechoic - black
![Page 7: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/7.jpg)
Ultrasound Basics
Uses sound waves(don’t worry about the physics ... that’s my job!)
ProsReal timeNon invasivePortableNon ionizingRelatively lower cost vs CT/MRI
![Page 8: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/8.jpg)
Ultrasound Basics
POSTERIOR SHADOWING POSTERIOR ENHANCEMENT
o Hyperechoic structures reflect a majority of sound waves, leaving a dark shadow behind them
o Increased echogenicity posterior to a structure. Implies fluid containing such as a cyst
Gallstone with shadowing
Ribs with shadowing
Hepatic cyst with enhanced transmission
![Page 9: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/9.jpg)
Ultrasound Indications
Characterize massFluid search/abscessRUQ or abdominal painJaundiceSplenomegalyFlank painAAA screeningUS-guided procedures
AND SO MANY MORE . . .
![Page 10: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/10.jpg)
What’s Included?
ABDOMEN COMPLETE RUQ US
Pancreas (if visible)
Liver
Gallbladder
Bile ducts
Kidneys
Spleen
Some liver
Gallbladder
Bile ducts
AND THAT’S IT. . . ie order this for suspected GB pathology
![Page 11: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/11.jpg)
Module Outline
I. Basics & IndicationsII. Abdominal US AnatomyIII. CasesIV. Wrap up/Questions
![Page 12: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/12.jpg)
Transverse
IVC
Liver Anatomy
?
?
??
?
Longitudinal
?
?
Kidney
Liver?
?
?
?
?
?
?
?
Morison’s Pouch
?
![Page 13: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/13.jpg)
Gallbladder Anatomy
Gallstones
GB
![Page 14: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/14.jpg)
Pancreas Anatomy
Transverse
?
?
? ?
?
?
?
?
?
?
![Page 15: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/15.jpg)
Spleen Anatomy
Diaphragm
![Page 16: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/16.jpg)
Module Outline
I. Basics & IndicationsII. Abdominal US AnatomyIII. CasesIV. Wrap up/Questions
![Page 17: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/17.jpg)
Case #1: 54yo right flank pain
Round anechoic lesion with imperceptible walls and posterior enhancement = Simple cyst
![Page 18: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/18.jpg)
Case #1: 54yo right flank pain
Round anechoic lesion with imperceptible walls and posterior enhancement = Simple cyst
Renal simple cyst is very common finding
CYST requires:AnechoicImperceptible wallsPosterior enhancementNo solid or vascular components
![Page 19: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/19.jpg)
Case #2: History withheld
Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute
cholecystitis. Normal on bottom for comparison
![Page 20: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/20.jpg)
Case #2: History withheld
Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on
bottom for comparison
Acute Cholecystitis
Imaging findings:GallstonesThickened GB wallPericholecystic fluidMurphy’s sign+/- perforation
![Page 21: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/21.jpg)
Case #3: 60yoM jaundice, history of hepatitis C
Heterogeneous hypoechoic liver mass. Ill defined
![Page 22: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/22.jpg)
Case #3: 60yoM jaundice, history of hepatitis C
Heterogeneous hypoechoic liver mass. Ill defined
Hepatocellular CA
Differential includes primary liver tumor or metastasis.
Remember history of HCV, thus more likely HCC
Imaging findings:Hypo or hyperechoic liver massInternal vascularityCan be ill definedBetter characterized on MRI
![Page 23: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/23.jpg)
Case #4: 45yoM midline pain hx of gallstones
Heterogeneous hypoechoic enlarged pancreas. Ill defined. Patient tender when scanning over this region = Acute pancreatitis
![Page 24: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/24.jpg)
Acute Pancreatitis
Imaging findings:Enlarged pancreasIll defined bordersPeripancreatic fluidHypoechoic on US
Pancreas often not well visualized on ultrasound (bowel gas)
Remember pancreatitis is clinical diagnosis!
CT can be helpful for complicationsNecrosis, fluid collections, pseuodocyst, walled-off necrosis
Case #4: 45yoM midline pain
Heterogeneous hypoechoic enlarged pancreas. Ill defined. Patient tender when scanning over this
region = Acute pancreatitis
![Page 25: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/25.jpg)
Points for pointing out the nodular liver! Anechoic fluid in the peritoneal spaces around the liver and right
kidney = Ascites
Case #5: 38yo cirrhosis
![Page 26: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/26.jpg)
Case #5: 38yo cirrhosis
US is EXCELLENT to search for & measure ascites/fluidCan also use US guidance to drain ascites
Avoid bowel and other organs
![Page 27: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/27.jpg)
BONUS Case #6: 80yo breast mass
US is EXCELLENT in biopsy & drainage procedure guidance, to include breast, thyroid, lymph node
![Page 28: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/28.jpg)
Module Outline
I. Basics & IndicationsII. Abdominal US AnatomyIII. CasesIV. Wrap up/Questions
![Page 29: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/29.jpg)
Think Back!
Sound waves - no ionizing rads
Hyper- iso- hypo- anechoic
Full abdominal US (Pancreas, liver, gallbladder, bile ducts, kidneys, spleen) vs. RUQ US (some liver, gallbladder, bile ducts)
Simple cyst: anechoic, imperceptible wall, posterior enhancement
CT for pancreatitis complications; US great for ascites and paracentesis
![Page 30: RADY Resident Symposium: Ultrasound · Case #2: History withheld Multiple shadowing stones. Wall thickening, pericholecystic fluid = Acute cholecystitis. Normal on bottom for comparison](https://reader033.vdocuments.us/reader033/viewer/2022042113/5e8f3cf807aab210e6466cb1/html5/thumbnails/30.jpg)
More at www.rads.web.unc.edu www.msrads.web.unc.eduand @UNCRadRes
Thank you!