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1000705_EUS@GU emergencies

Acute appendicitis & Pneumoperitoneum

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History & PEEUSScan

2

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3

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Problem 1

?

1. 6

2. 83. 104. 12

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Longitudinal ultrasound view of the

normal right kidney

5

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Transverse ultrasound view of the

normal right kidney

6

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Normal left kidney

7

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Normal filled urinary bladder

8

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Male Pelvis

9

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Problem 2

6530Severity 9/10

?1. 2.

3. 4.

10

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Acute flank pain/

suspected renal colic

EUS:

obstructionAAA

11

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Overview of degrees of hydronephrosis

12

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Renal stone

EUS:

Hyperdense lesion with acoustic shadow

13

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71F, left flank pain

14
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Ureteral%20stone_71F_05905469/Ureteral%20stone_71F_05905469.wmv

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Problem 3

?

1. Renal stone

2. Hydronephrosis

3. Hydroureter

4. Ureteral stone

5. UVJ stone
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Ureteral%20stone_71F_05905469/Ureteral%20stone_71F_05905469.wmv

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Left UVJ stone

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/UVJ%20stone_39F_08835452/UVJ%20stone.mpg

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Left UPJ stone with obstruction

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/UPJ%20stone%20with%20APN_66F_01554738/UPJ%20stone%20with%20APN_66F_01554738.mpg

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UVJ stone

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http://localhost/var/www/apps/conversion/current/tmp/scratch_5/Right%20UVJ%20stone_%E9%80%B8%E6%96%87.wmv

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59M, left flank pain & hematuria

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/CV/AAA_Hematuria_59M_07064093/AAA_Hematuria_59M_07064093_%E8%AC%9D%E5%BF%A0%E7%BE%A96hrs%20later.wmvhttp://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/CV/AAA_Hematuria_59M_07064093/AAA_Hematuria_59M_07064093.wmv

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56F, severe left back pain

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Hydronephrosis%20&%20urine%20extravasation_56F_14543235/Urine%20extravasation_56F_14543235.wmv

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Bladder

?Acute urine retension

U/Cfailure ? Bladder size evaluation

21

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(ml) =

* * * 0.75 (error: 15-35%)

Bladder index volume (AP * Transverse) 2.4cm2 = 2ml22

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63M, right flank pain & hematuria

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Bladder%20tumor_63M_15954436/Bladder%20tumor_63M_15954436.wmv

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21F with painful voiding

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http://localhost/var/www/apps/conversion/current/tmp/scratch_5/Cystitis_Ketamine_21F_05528186.wmv%20-%20%E6%8D%B7%E5%BE%91.lnk

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Problem 4

70BUN/Cr 25/0.789/5.6

?1. Pre-renal cause

2. Intrinsic cause3. Post-renal cause4.

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Acute renal failure

:

post-renal obstruction

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/AUR/AUR%20&%20bilateral%20hydronephrosis.wmv

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Renal cyst

EUS1. smooth, round, or oval

2. no internal echo3. well-defined margin

4. posterior enhancement28

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61F, fever & left flank pain

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Infected%20renal%20cyst_61F_01768766/Infected%20renal%20cyst_62F_01768766_1.wmv

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61F, fever & left flank pain

30

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Problem 5

49

?1. Emphysematous pyelonephritis2.

Acute pyelonephritis

3. Renal abscess4. Obstructive uropathy

31

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Complicated UTI

(APN & renal abscess)EUS

1. Risk factors2. Treatment failure

3. Severe sepsis/septic shock

32

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50F, septic shock

33

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52F, chills and left flank pain

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Renal%20abscess_51F_16403339/Left%20renal%20abscess_52F_16403339.wmv

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68F, fever with pyuria/ bedridden

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Pyonephrosis_69F_04386319/Pyonephrosis_69F_04386319.wmv

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Pyonephrosis

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Pyonephrosis_59M_16496479/Pyonephrosis.mpg

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Urosepsis with obstruction

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Urosepsis_Septic%20shock%20with%20right%20obstructive%20uropathy_08365786_85F/Right%20hydronephrosis%20with%20multiple%20bil%20renal%20stones_85F_08365786_990727.mpg

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49F, fever & left flank pain * 2wks

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Emphysematous%20pyelonephritis_49F_16171951/Emphysematous%20pyelonephritis_49F_16171951_1.wmv

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49F, fever & left flank pain * 2wks

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Emphysematous pyelonephritis

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Emphysematous%20pyelonephritis_78F_01804132/Emphysematous%20pyelonephritis_78F_01804132.wmv

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Emphysematous pyelonephritis

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68F, fever & chills

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Emphysematous%20cystitis_68F_03776507/Emphysematous%20cystitis_68F_03776507.wmv

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68F, fever & chills

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Fever with right flank/back pain

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/SST/Psoas%20muscle%20abscess_87F_06755277/Psoas%20muscle%20abscess_88F_06755277.wmv

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Right flank redness s/p PCN removal

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Diffi lt idi d d f ti f
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Right%20peri-renal%20abscess%20&%20obstructive%20uropathy_57F_15929961/Right%20peri-renal%20abscess%20&%20obstructive%20uropathy_57F_15929961.wmv

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Difficult voiding and defecation for

two weeks

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Recto-vesicle%20fistula_69M_05684079/Recto-vesicle%20fistula_70M_05684079.wmv

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Problem 6

25?1. Sonography

2. Contrast-enhanced CT

3. IVP

4. MRI

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Trauma

EUSHighly operator dependent

gross hematuria,orCECT

48

57M l ft fl k i /

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57M, severe left flank pain s/p

ESWL

49

57M l ft fl k i /
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Subcapsular%20renal%20hematoma%20post%20ESWL%20&%20right%20renal%20tumor_57M_10146734/Subcapsular%20renal%20hematoma%20post%20ESWL_57M_10146734.wmv

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57M, severe left flank pain s/p

ESWL

50

65M i ht fl k i d

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65M, right flank pain and

hypotension

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95M bd i l i ith bl d
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Right%20renal%20hemorrhage%20&%20retroperitoneal%20hematoma_64M_06389445/Renal%20rupture_65M_06389445.wmv

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95M, abdominal pain with bloody

ascites

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http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Bladder%20rupture_95M_09492498/20091214_1505.mpg

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Others

What about kidneys ??

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P i f l l ft fl k

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Painful left flank
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Renal%20infarction_52F_06449136/Renal%20infarction_52F_06449136.wmv

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Right flank pain

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Right flank pain

Painful right flank with family
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/RK%20hemorrhage_67F_04386319/RK%20hemorrhage_67F_04386319.wmv

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Painful right flank with family

history of urolithiasis
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Angiomyolipoma_36F_12051707/Angiomyolipoma_36F_12051707_2.wmvhttp://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/Angiomyolipoma_36F_12051707/Angiomyolipoma_36F_12051707_1.wmv

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Left flank pain
http://localhost/var/www/apps/conversion/current/SKH_EUS%20cases/GU/TCC%20with%20obstruction_52m_01246426/TCC%20with%20obstruction_52m_01246426.wmv

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Appendicitis

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Problem 7

AppendicitisAlvaradoscore ?1. Nausea/Vomiting

2. Diarrhea

3. Migration

4. RLQ tenderness

5. Leukocytosis

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Alvarado Score

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Graded compression technique

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GI tract lesions on sonography

1. (>4mm)

2.

3.

4.

5.

6. (LN, fat, ascites)

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Problem 8

?1. Blind-ended tubular structure

2. Non-compressible appendix

3. Diameter 6mm

4. Dome sign

5. Appendicolith

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Appendicitis

Eur Radiol. 2002;12:1748-61
http://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdfhttp://www.springerlink.com/content/g5k8hrh2d88p4bff/fulltext.pdf

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Landmark of Appendix

RLQ

Iliac crest

Psoas muscle

Iliac vessels Cecum & A-colon

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Acute appendicitis

Diameter 6mm J Ultrasound Med 2006;25:87-97

Appendiceal outer diameter for

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Appendiceal outer diameter for

appendiceal mucocele VS appendicitis

Lien WC, AJEM (2006) 24, 801805

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Pneumoperitoneum

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Anatomic consideration

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Scanning Method

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Intraperitoneal free air

Air

Echogenic areas +

Posterior reverberation (ring-down)artifacts

Shifting phenomenon

Location

Epigastric region (Supine)

Left lateral decubitus position

Others: echogenic fluid

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Pneumoperitoneum

Echogenic line

Ring-down artifacts

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Intraperitoneal free air

Moriwaki, Y. et al. Arch Surg 2009;144:137-141.

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Effect of position change

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Effect of respiration

L: lung;

P: neumo eritoneum

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Scissors Maneuver

J Clin Ultrasound 2004; 32:381-385Okkes Ibrahim Karahan, JOURNAL OF CLINICAL ULTRASOUND 2004

EPSS

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EPSSEnhancement of the peritoneal stripe sign

Ashwin Asrani

Emerg Radiol 2007

Ai b t t IPFA

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Air but not IPFA

Air in Lung

Air in GI tract

Subcutaneous emphysema

Chilaiditi syndrome

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Sensitivity Specificity PPV NPV accuracy

US 92 53 95 39 88

X-ray 78 53 94 20 76

BJS 2002; 89:351-354BJS 2002

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IPFA by US in Trauma and acute abdomen

Moriwaki, Y. et al. Arch Surg 2009;144:137-141.

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1000705_EUS@嘉基ER

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