急診超音波在

下腹部和骨骼軟組織的應用

陳國智醫師

新光醫院急診醫學科

輔仁大學醫學系

中華民國醫用超音波學會指導醫師

1

Lower abdominal echo

2

Scenario

25 y/o female

C/O: acute low abdominal pain

w/ cold sweating, VAS: 8/10

BP: 60/40 mmHg; HR: 130 bpm

Menstruation: 2nd day

Your impression ?

Next step ?

2008 ACEP EUS guidelines

• Describe the relevant local anatomy of pelvic cavity

• Describe the role of focused US in first-trimester pregnancy pain and bleeding.

• Understand the role of US and quantitative β-hCG in a clinical algorithm for first-

trimester pregnancy pain and bleeding.

• Understand the differential diagnosis of early pregnancy including intrauterine

pregnancy, embryonic demise, molar pregnancy, ectopic pregnancy, and

indeterminate classes.

• Recognize the relevant focused findings and pitfalls when evaluating for early

intrauterine pregnancy and ectopic pregnancy.

– Early embryonic structures

– Location of embryonic structures in pelvis

– Findings of ectopic pregnancy

– Pseudogestational sac

– Adnexal masses

Role of EUS for OB/GYN

• Identify an IUP

• Establish fetal viability

• Hemodynamic instability in a female patient

• Trauma and pregnancy

• Localization of IUD/foreign body

• Identify sources of pelvic pain and bleeding in

pregnant & non-pregnant patients

Trans-abdominal US 1st choice for emergency physician

• Use a lower frequency transducer: 3.5 –5 mHz

• Better penetration, larger field of view

• It should be the initial imaging window to assess

for

– Advanced IUP

– Fibroids/masses

– Pelvic fluid

• The bladder should be full to provide an acoustic

window

Transvaginal US

• Use a higher frequency transducer: 6.0-7.5mHz

• Provides optimal imaging of:

– Endometrium

– Myometrium

– Cul-de-sac

– Ovaries

• A full bladder is not necessary for this approach

• Is usually better tolerated by patients

Normal Pelvic Anatomy

Trans-Abdominal Scan

Normal Pelvic Scan

TVS: Sagittal View

Pelvic Scan (TVS)

TAS versus TVS

Pelvic Sagittal View

US Findings in IUP

• Gestational sac

• Double decidual sac sign (DDSS)

• Yolk sac

• Embryo

• Cardiac activity

Intradecidual Sign

Gestational Sac

• Anechoic area within the uterus

surrounded by two bright echogenic rings

– Decidua vera (the outer ring)

– Decidua capsularis (the inner ring)

• This is referred to as the double decidual

sac sign (DDSS)

Double Decidual Sign

Yolk Sac

• First embryonic structure that can be

detected sonographically

• Visualized approximately 5-6 weeks after

the last menstrual period

• Bright, ring like structure within the GS

• Should be readily seen when the GS sac

is greater than 10 mm (using EVS)

Yolk Sac

Embryo & Yolk Sac

Intrauterine embryo & yolk sac

Intrauterine fetus

and yolk sac & amnion

A Fetal Heart Beat

• An important prognostic indicator

• The rate of spontaneous abortion is extremely low (2- 4%) after the detection of normal embryonic cardiac activity

• The normal fetal heart rate in early pregnancy is 112-136

43F complained low

abdominal pain

What do you see ?

26

Ectopic pregnancy

Ectopic Pregnancy

• 2% of all pregnancies, 7-13% of those who

present with pain or bleeding

• Incidence quadrupled in last 20 years

• 50% were missed before widespread use

of ultrasound

• Still the #1 cause of maternal death in

1st trimester

Rule-out Ectopic Pregnancy

(saves time and money)

• Find an IUP

• Chance of both IUP and EP is 1/8000

• As high as 1/100 if pt takes fertility agents

β-hCG Levels

• Correlate roughly with gestational age

• Older algorithms relied on β-hCG

• One level means almost nothing

• Serial levels are helpful

• 40% ectopics have a β-hCG level <1000

Discriminatory Zone

• Def:

– The level of β-hCG at which findings of an

IUP are expected on sonography

• Titinalli 7th ed.

– TVS 1500 mIU/mL; TAS 6000 mIU/mL

• Rosen

– TVS 3000 mIU/mL; TAS 6500 mIU/mL

ß-hCG >discriminatory zone and empty

uterus is EP until proven otherwise

Sonographic Spectrum of EP • Ruptured ectopic pregnancy

• Definite ectopic pregnancy

• Extrauterine empty gestational sac

• Adenexal mass

• Pseudogestational sac

• Empty uterus

Ectopic Pregnancy

Empty uterus & free fluid in CDS

Empty Uterus & Complex fluid in CDS

Empty Uterus &

Free fluid in CDS & hepatorenal space

Complex adnexal mass

39F_33wk + ABD pain

Molar pregnancy

Estimation of GA

Pregnancy Dating

Crown Rump Length (CRL)

Biparietal Diameter

Femur Length

Fetal Heart Rate Determination

Location of appendix

Pregnancy 18wks & 30wks & Appendicitis

Main Goals in Non-pregnant

Patients • Determining the etiology of abdominal pain -

pelvic organs or other etiology

• Hemorrhagic ovarian cyst

• Ovarian torsion

• Ovarian hyperstimulation syndrome (OHSS)

• Tubo-ovarian abscess

• Fibroid (Leiomyoma)

Ruptured corpus luteum cyst

16F with low abdominal pain

Pregnancy test: negative

What do you see ?

49

Ruptured ovarian cyst with internal bleeding

OHSS

18F with low abdominal pain

What do you see ?

51

Pelvic Tumor

16F with severe low

abdominal pain

What do you see ?

52

Hematometria

47F with low abdominal pain

What do you see ?

53

Teratoma

39F with fever and low

abdominal pain

What do you see ?

54

TOA & Pyosalpinx

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

Question

• 請問下列何者非急性闌尾炎的超音波發現 ?

1. Blind-ended tubular structure

2. Non-compressible appendix

3. Diameter > 6mm

4. Dome sign

5. Appendicolith

Appendicitis

Eur Radiol. 2002;12:1748-61

• Diameter > 6mm (Cross section)

• Non-compressiblity of appendix

• Localized pain during compression with the transducer

• Alteration of the periappendiceal fat

(echogenic & non-compressible fat)

• Obstruction of the lumen by an appendicolith

• Hypervascularizaion in color Doppler of appendix and surrounding fat

Landmark of Appendix

• RLQ

– Iliac crest

– Psoas muscle

– Iliac vessels

– Cecum & A-colon

Cecum, Ileum and Appendicitis

Appendicitis with obvious cecum and ileum

Appendicolith

Appendicitis with appendicolith

學習認Landmark

Ruptured appendicits

10M with low abdominal pain

What do you see ?

65

Ruptured appendicitis

14M with low abdominal pain

What do you see ?

66

Ruptured appendicitis with abscess and ileus

47M with RLQ and low

abdominal pain

What do you see ?

67

Ruptured appendicitis

27F, pregnancy at 14 wk

RLQ pain

What do you see ?

68

Appendicitis

Colon

21M with RLQ pain

What do you see ?

70

Cecal diverticulitis

問題

• 請問下列何者為大腸憩室炎的超音波發現 ?

1. Corona sign

2. Target sign

3. Curtain sign

4. Dome sign

5. Veiled Kidney sign

21M with RLQ pain

Cecal diverticulitis

Dome sign:

acute colonic diverticulitis

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

Copyright © Radiological Society of North America, 2003

O'Malley, M. E. et al. Radiographics 2003;23:59-72

Right-sided diverticulitis in a 32-year-old woman

with right lower quadrant pain and fever

48M with right abdominal pain

A-colon diverticulitis

18M with RLQ pain

Cecal diverticulitis

25F with LLQ pain

S-colon diverticulitis

26F with RUQ pain

A-T colon junction diverticulitis

32M with RLQ pain

Terminal ileum diverticulitis

39F with LLQ pain

What do you see ?

80

Left UVJ stone

Left UVJ stone

81

59M, left flank pain & hematuria

82 Ruptured AAA

21F with painful voiding

83 Ketamine-induced cystitis

69M, diffuse low abdominal pain Difficult voiding and defecation for two weeks

84

Colovesicular fistula

95M, abdominal pain with bloody

ascites

85 Bladder rupture

Soft tissue & MSK echo

86

請問超音波在MSK的應用不包含下列何者

1. 診斷蜂窩性組織炎

2. 辨識肢體腫脹是否為深部靜脈栓塞所致

3. 尋找異物

4. 診斷關節處骨折

5. 辨識是否有軟組織膿瘍

87

Outlines

• US anatomic considerations

• Skin and soft tissue infection

• Long Bony fracture evaluation

正常組織超音波影像 • Skin

– Echogenic

• Subcutaneous tissue – Hypoechoic

– Traverse by irregular strands of hyperechoic connective tissue

• Fascial planes – Hyperechoic; regular thickness

• Muscles – Striated appearance on long axis scan

• Tendon – Fibrillar; echogenic

• Vascular structures – Anechoic (Artery versus Vein)

• Lymph nodes – Irregular, circular, echogenic; with hypoechoic rim

• Bones – Echogenic cortices and dense acoustic shadows

掃描注意事項

• 高解析線形探頭 (5-10MHz)為第一首選

• 注意深度(depth)和焦點(focus)的設定

• 適當應用探頭施壓

• 至少掃描兩個介面 (longitudinal & transverse)

• 考慮和對側比較 & 呈現在同一畫面 (Split screen)

• 如何改善掃描品質 – Stand-off pad

– Water/gel-filled glove

– Water bath technique

Water/gel-filled glove

EUS在皮膚 & 軟組織感染的應用

• 須熟悉正常超音波軟組織影像

• 認識週遭組織及結構

• 協助設定最佳切除及引流路徑

• 正確診斷不明顯膿瘍

診斷

• 正確定位不明顯膿瘍

定位

• 協助膿瘍引流

處置

皮膚 & 軟組織感染

• Cellulitis – Cobblestone-like appearance

• Subcutaneous abscess – Variable appearance

– Most: hypoechoic; spherical mass

– Content: • Hyperechoic sediment

• Septae

• Gas

• Isoechoic or hyperechoic

• Liquefied pus – induced motion of the

content

• Necrotizing fasciitis – Marked thickened of SC layer

– A layer of anechoic fluid, • greater than 4 mm

• adjacent to deep fascia

– Subcuatneous gas • Acoustic shadow

• Reverberation artifact

Cellulitis

• Nonspecific

• Indicative of edema

• Skin

• Subcutaneous tissue

• Compare to unaffected side

Normal v.s. Cellulitis

EUS improves accuracy of superficial

abscess detection

Squire BT, et al. AEM. 2005;12:601-606

NTUH experience

• diffuse thickening of the SC tissue

• a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer

• 66 patients (17,NF)

• Sensitivity: 88.2%

• Specificity: 93.3%

• PPV: 83.3%

• NPV: 95.4%

• Accuarcy: 91.9

Yen ZS, et al. AEM. 2002;9:1448-1451

EUS for DVT survey

• Primary component

– Visualize the venous structures

– Detect gray-scale compressibility

– Lack of compressibility DVT

• Secondary component

– Use of Doppler to evaluate for abnormal flow

No complete compression

1. Presence of a clot

2. Inadequate pressure on the

transducer

Position for femoral area

Femoral vessels

72F with fever and left leg pain

102

骨折評估

• 肋骨骨折

• 胸骨骨折

• 長骨骨折

• 堅困環境骨折

• 骨折復位

• 脫位復位

• FASTER

骨折評估

• 骨表面產生不連續線條

• 骨折周圍低回音血腫

• 掃描時注意最痛點

• 至少進行兩個介面掃描

Rib

Rib fracture

Rib fracture

Normal sternum

Sternal body fracture

Femur

Femoral shaft fracture

Tibial shaft fracture

50M with abdominal pain

What do you see ?

113

Urachal cyst abscess

42F, low abdominal pain

What do you see ?

114

Abdominal wall hematoma

54F with fever and painful

back mass

What do you see ?

115

Back carbuncle

58M s/p thyroidectomy

116

Neck abscess

56M with left thigh pain

What do you see ?

117

Lymphadenopathy

75M with anal pain and fever

What do you see ?

118

Perianal abscess

50M, 釘槍打入腳趾

119 Identify toe FB

19M，打橄欖球受傷

120 Shoulder dislocation and reduction

78F with fever and right hip pain

121

Septic arthritis

Take Home Message

• Know anatomy

• Find landmark

• Recognize patterns

謝謝聆聽

歡迎指教及給予回饋

Juice119.pixnet.net

Juice119@gmail.com

123