Emergent diagnostic sonography in patients

presenting with acute abdomen

1000302_放射聯合討論會

新光醫院急診醫學科
陳國智醫師
中華民國醫用超音波學會指導醫師
ACEP 2008 EUS guidelines

Ann Emerg Med. 2009;53:550-570

 執行EUS應該注意的事情
• EUS不在取代正式的超音波檢查

• EUS是在協助急診醫師回答某些特定的問題

• 養成二分法(Binary thinking)的習慣進行EUS

• 認清操作者的經驗及儀器設備的限制是影響
EUS檢查結果的重要因素

• EUS的執行應對臨床處置有影響時才有價值
 It is only by
thorough history taking and
physical examination
that one can propound a
diagnosis
Suspected Modality
condition
XR US CT

Appendicitis + ++ +++

Perforation +++ ± ++

Pancreatitis + ++ +++

Diverticulitis + ± +++

Cholecystitis + +++ ++

Abscess + ++ +++

Intestinal +++ + ++

Obstruction +++ + ++

Inflammation + ± ++

Ischemia + ± ++

Aortic aneurysm + +++ +++

Rupture + ++ +++

Renal colic ++ ++ ++

Gynecological + +++ ++

Ruptured follicle +++ +

Ectopic pregnancy +++ +

5
Tubo-ovarian abscess + +++ ++
Pattern: Fluid
Anatomic consideration
Free peritoneal fluid

8
 FAST for SLOH
Systematic look for occult hemorrhage

9
Clear ascites
Cirrhosis
 Hemoperitoneum
Corpus luteum cyst rupture
Hemoperitoneum
Ectopic pregnancy
Hemoperitoneum
HCC rupture
Dirty ascites
SBP
 Discriminatory Zone
• Definition
– The level of βhCG at which findings of an IUP
are expected on sonography
• Titinalli
– TVS 1500 mIU/mL; TAS 6000 mIU/mL
• Rosen
– TVS 3000 mIU/mL; TAS 6500 mIU/mL

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Pattern: Gas
Anatomic consideration
Scanning Method
 Intraperitoneal free air
• Air
– Echogenic areas +
– Posterior reverberation (ring-down)artifacts
– Shifting phenomenon
• Location
– Epigastric region (Supine)
– Left lateral decubitus position
• Others: echogenic fluid
Pneumoperitoneum

• Echogenic line

• Ring-down artifacts
 Air but not IPFA
• Air in Lung
• Air in GI tract
• Subcutaneous emphysema
• Chilaiditi syndrome
 Pneumoperitoneum
Delayed PPU w/ ascites
Pneumoperitoneum
PPU
Subcuatneous emphysema
Pattern: Obstruction
Hydronephrosis

26
 Hydronephrosis
APN w/o right ureteral stone
Hydronephrosis
Pyonephrosis
Acute calculous cholecystitis
GB empyema
CBD stone and dilatation
GI tract
Graded compression technique
GI tract lesions on sonography

1. 腸胃道壁增厚 (>4mm)
2. 腸胃道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites)
Alvarado Score
 Acute appendicitis

The order of occurrence of the symptoms

1. Pain, usually epigastric or umbilical
2. Anorexia, nausea, or vomiting
3. Tenderness-somwhere in the abdomen or
pelvis
4. Fever
5. Leukocytosis

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Appendicitis

Eur Radiol. 2002;12:1748-61

Acute appendicitis
 Appendicitis
Pregnancy @ 14 weeks
 Dome sign:
acute colonic diverticulitis

J Clin Ultrasound. 2000;28:340-6.

Diverticulitis
Enterocolitis
Bisection Approximation Method
for GI obstruction

1 2

4
3

Hepatogastroenterology. 2006;53:547-51.
 Bisection Approximation Method
Location of US examination (From 1 – 5) Possible
lesion site
1. A-C 2. D-C 3. Rectum 4. IC region 5. Gastric
outlet or
duodenum
Dilated Collapsed From 1-2

Dilated Dilated Collapsed From 2-3

Collapsed - - Dilated From 1-4

Collapsed - - Collapsed Dilated From 4-5

Collapsed - - Collapsed Collapsed Above 5

Acute intestinal obstruction

Fold of Kerckring
45
Eur Radiol. 2002;12:1748-61
Enteritis with bowel obstruction
Ileitis with bowel obstruction
Adhesion ileus with SBO
Gallstone ileus
Intussusception
Intussusception
Lymphoma
 Hernia
Incarcerated inguinal hernia
 Hernia
Incarcerated umbilical hernia
Colitis
Colon cancer
Colon cancer
Carcinomatosis
Sclerosing encapsulating peritonitis
Epiploic appendagitis
Vascular system
Abdominal aortic aneurysm
Aortic dissection
SMA occlusion
Volvulus
Angiomyolipoma
 Extra-abdominal cause
Abdominal wall hematoma
Extra-abdominal cause
Pneumonia
 Take Home Message
• 診斷急性腹痛最重要的是病史和理學檢查

• 善用各種診斷工具, 超音波不是唯一

• 熟悉超音波的各種基本形態 : Pattern