Gallbladder Explosion

Authored by Sandi Chen, and Mario Corro Reviewed by SIUH Sono Division

85 year old female with history of HTN and hypothyroidism presents to ED for epigastric pain that started a week ago. Pain is postprandial, moderate in intensity, stabbing, continuous and radiating to the RUQ. Associated with nausea but no vomiting. Currently denies abdominal pain but complains of nausea. She denies any fever, chills, constipation or diarrhea. The following images were obtained.

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Questions:

 

1. What is seen on the above ultrasound image?

 

2. What disease processes could lead to this ultrasound finding?

 

3.  What are the ultrasound criteria for cholelithiasis? 

 

4. What are  sonographic findings in acute cholecystitis? 

 

5. What complications can arise if the above condition is not treated?

 

Answers:

  1. Gallbladder perforation (yellow arrow)

    1. Pericholecystic fluid and 

    2. True gallbladder lumen filled with stones and sludge (red arrow)

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2. Gallbladder perforation is most commonly due to occlusion of the cystic duct by gallstone and subsequent retention of contents. The associated rise in luminal pressure limits venous and lymphatic drainage, leading to vascular compromise, necrosis, and ultimately perforation. May also arise due to laparoscopic cholecystectomy.

 3. Cholelithiasis (blue arrow): highly reflective echogenic focus within gallbladder lumen, normally with posterior acoustic shadowing. Stones will also show gravity-dependent movement.

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4.Cholecystitis:   * = most sensitive

    1. Presence of ultrasonic Murphy sign*

    2. Gallstones visualized, especially if in gallbladder neck*

    3. Anterior gallbladder wall thickening >3mm

    4. Presence of pericholecystic fluid

    5. Hydrops (>5x10cm)

(None of the above signs are pathognomonic)

5.Pericholecystic abscess, cholecystoenteric or cholecystobiliary fistula formation, bile peritonitis, pancreatitis, subphrenic or hepatic abscess formation

EKG of the Week 2018 11-4

This EKG comes courtesy of Dr. Majlesi.

An 81 y/o male presents to the ED complaining of generalized weakness, difficulty speaking and shuffling gait. He has no chest pain or SOB. His vital signs are normal.

His EKG is below.

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1.       What are the findings on this EKG?

2.       What can explain these findings?

ANSWER:

The EKG shows an extreme right axis deviation with negative complexes in leads I and II and positive complexes in lead aVR. 

Several things can cause these findings including COPD, limb lead reversal and dextrocardia. In this case, the patient was found to have situs inversus.

 

In a normal EKG, the P waves in leads I and II should be upright and the P waves in lead aVR should be inverted. This EKG shows the opposite - negative complexes with inverted P waves in leads I and II and positive complexes and upright P waves in lead aVR.

This pattern can be seen in severe COPD or in limb lead reversal (if the right arm lead is placed on the left arm and the left arm lead is placed on the right arm). However in that scenario, the precordial leads should be normal. In our EKG, the R wave progression in the precordial leads is reversed. The QRS complex is positive in lead V1 and negative in lead V6. This occurs because the entire heart is reversed.

Our patient’s Chest X-ray is below.

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As you can see, the heart is reversed and on the right side of the body. Additionally, you can see the liver on the left side and the stomach bubble on the right side. This represents complete situs inversus. This is why the patient’s EKG is essentially reversed.

92 Year Old Male With Difficulty Breathing

Authored by: Ahad Anjum, Brittany Choe Edited by: SIUH Ultrasound Division

92 y M hx of afib, CLL, Lymphoma pw difficulty breathing and cough. The following was found on bedside sono of the right lung. 

QUESTIONS:

1. What is seen on the above ultrasound image?

2. What disease processes could lead to this ultrasound finding? 

3.  What are the names of the ultrasound signs seen above? 

4. What is Light's Criteria? What would you expect the results to show if you were to aspirate a sample from this finding? 

ANSWERS

1. Pleural effusion with debris (red star), most likely indicative of an exudative effusion 

2.  Malignancy, pneumonia/parapneumonic effusion, lymphoma

3. Tongue Sign (white arrow) showing the lung parenchyma floating in hypo echoic fluid indicating a pleural effusion, Spine sign (black arrow) indicates a fluid filled medium above the diaphragm in which the spine is visualized on ultrasound, which is normally not seen through a regularly aerated lung 

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4. Pleural fluid protein/serum protein >0.5, Pleural fluid LDH/Serum LDH >0.6, Pleural fluid LDH > 2/3 upper limit of LDH 

FIX 2018!

This past week marks the 2nd Annual FIX (FemInEM Idea Exchange) 2018 conference. From all feedback, the conference was a huge success. Having attended this conference for the 2nd year in a row, I can attest to the fact that the conference is hugely inspirational, motivating and in many ways, practice changing. For those of you who have not had the chance to attend - plan to check it out one last time in NYC next year!

Here are some thoughts from those who attended from SIUH:

The FIX conference was an incredibly unique educational experience that I highly recommend.  Powerful speakers were brought in from around the world to share their stories and experiences to help empower emergency medicine physicians. This conference showed me the strength that comes from an incredible community of physicians joining together to support one another. - Emily Bokser MD, PGYIII

It was an incredible conference. Diverse speaker perspectives, excellent and inspiring topics. I felt like it could have been curated specifically for the physician I am now, in this exact moment of my life and career, and yet I know many others felt the same way. Can’t wait for next year.” - Amanda Smith MD, Attending Physician

If you didn’t get a chance to attend, check out this podcast about it. Thank you to Dara Kass (our alumnus!) and all of her incredible staff for putting together such a memorable conference.

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EKG of the Week 2018 10-7

This EKG comes courtesy of Dr. O’Halloran and Dr. Litvak.

A 74 year old female presents to the emergency department with Chest pain and SOB. She had an anterior wall STEMI 1 month prior and had stents placed. At the time of evaluation in the ED she is asymptomatic. Her EKG is below.

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1.    What does the EKG demonstrate?

2.    What can cause these EKG findings?

ANSWER:

The EKG shows ST elevations and Q waves in Leads V1-V6.

In the acute setting this would be consistent with an evolving anterior wall MI. One month after a STEMI, these findings can be caused a left ventricular aneurysm.

 

The EKG demonstrates ST elevations in leads V1-V6 with Q waves in the same leads. There are no reciprocal depressions. This pattern in a patient >2 weeks after a STEMI suggests a ventricular aneurysm. This is a potential complication of an MI. The most common location of a ventricular aneurysm is the anterior wall.

 

The patient had an echocardiogram which showed paradoxical movement of the left ventricular wall.

 

Patients with LV aneurysm are at risk for ventricular arrhythmias and sudden cardiac death.

October is Diversity & Health Equity Month @ Northwell!

October marks Northwell’s annual Diversity & Health Equity month. Throughout this month, Northwell has made a commitment to raising awareness of the importance of fostering an environment in which promoting diversity amongst its staff and faculty is paramount in advancing its mission. Everyday this month, Northwell has put together at least 1 to 2 events to promote faculty development in specific topics related to health equity in a diverse climate. I had the ability to attend one of these event this past week entitled “Diverse Connections: Professional Development Series” where I was able to engage with some leaders within the Northwell network and learn about their diverse backgrounds and career progressions. It was enlightening to know that Northwell is committed towards promoting staff and faculty that reflect the diverse communities in which it resides.

Below are some of the takeaway points from the panel discussion that I thought worthy to highlight:

  1. A truly successful business, any business, needs to understand the importance of having a diverse staff and leadership so as to reflect the population it is working within

  2. Mentors/Sponsors may play a profoundly important role in changing the course of your career. Find someone you would like to emulate in your future career and ask to meet and talk. You will rarely find someone who will refuse to do so.

  3. Keep learning! All the years of schooling we’ve been through may seem like enough but we will never grow if we don’t continue to challenge ourselves and learn.

  4. Work/Life Balance does not exist! Think of it more of a Work/Life Integration and you will (hopefully) feel less guilty when missing the next family wedding.

Below is a calendar of the events scheduled for October. Take some time out to attend one!

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EKG of the Week 2018 9-9

This EKG comes courtesy of Dr. Yousseff.

A 25 year old male presented to participate in an elective research study. He had no complaints. A screening EKG was performed.

Vital Signs: Pulse – 50, R -16, BP 120.70.

His EKG is below.

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1.       What is the rhythm?

2.       How would you manage this patient?

ANSWER:

The rhythm is 3rd degree AV block. In this patient it turned out to be congenital.

This patient is asymptomatic. In asymptomatic congenital complete AV block, no specific treatment is needed.

 

The EKG demonstrates a bradycardia with dropped P waves, regular R-R intervals and irregular P-R intervals. This is consistent with 3rd degree AV block.

In congenital 3rd degree AV block, treatment depends on whether or not the patient has structural cardiac abnormalities. If the echocardiogram demonstrates structural abnormalities of the heart, treatment includes placement of a permanent pacemaker. If there are no structural abnormalities and the patient is asymptomatic, pacemaker placement can be delayed.

In this patient, he remembered being told as a child that he had “some kind of block in his heart”. He in fact had congenital 3rd degree AV block. His echo was normal. So, placement of a pacemaker was delayed. Ultimately most of these patients become symptomatic at some point in their life and they then require pacemaker placement.

The algorithm below is helpful for diagnosing bradyarrhythmias.

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