Old lady complained cough and dyspnea for 2 weeks CXR revealed massive left side pleural effusion In this video, you can see massive pleural effusion on left side and heart is visible on right side of sternum.
6 year-old girl complained abdominal pain. She had right lower quadrant tenderness on physical examination. Referred from LMD for ruling out appendicitis. The best way to rule out appendicitis is to find normal appendix. Multiple enlarged mesenteric lymph nodes can also be found in this video.
Prevalence of appendicitis in Western country: 7-8% Useful technique: Graded Compression 3 major goals of US 1. Exclusion of alternative disease 2. Comfirmation of typical appendicitis 3. Ruling out by providing a normal appendix
STATEMENT 1 The use of ultrasound imaging should be a routine procedure in every patient with suspected appendicitis. Consensus levels of agreement: A+ 16/18; A– 2/18
STATEMENT 2 Routine sonography in all patients with suspected appendicitis halves the rate of unnecessary surgery (negative laparotomy rate). Consensus levels of agreement: A+ 14/18; A– 4/18
Examination technique: 1. Simple search at the point of maximal tenderness 2. Systematic localization of ascending colon, cecal pole, terminal ileum and the origin of appendix 3. Graded compression 4. Left oblique body position in obese patient
STATEMENT 3 The graded compression technique should be used for visualization of the appendix. Consensus levels of agreement: A+ 18/18
STATEMENT 4 Anatomical variations require a systematic examination technique for identification of the appendix. Consensus levels of agreement: A+ 17/18; A– 1/18
Primary signs of acute appendicitis 1. Maximum outer diameter of more than 6mm 2. Maximal tenderness over the thickened appendix 3. Incompressibility of teh inflamed appendix 4. (Large) appendicoliths 5. Hypervascularity in color Doppler in uncomplicateed cases 6. Loss of stratification in gangrenous appeendicitis Secondary signs of acute appendicitis (in the surroundings) 1. Hyperechoic periappendiceal tissue 2. Complex fluid collection (pericecal abscess) 3. Mesenteric lympadenopathy 4. Periappendiceal fluid
3 most important criteria in the conformation of acute appendicitis 1. Max. diameter of appendix > 6 mm 2. Maximum pain over the appendix 3. Hyperechoic periappendiceal tissue
STATEMENT 5 A thickened appendix at the point of maximum tenderness and hyperechoic periappendiceal tissue are the most important signs of appendicitis. Consensus levels of agreement: A+ 15/17; A– 2/17
STATEMENT 6 Adequate training is a precondition for sonographic diagnosis of acute appendicitis. Consensus levels of agreement: A+ 18/18
False-negative 1. Non-visulization of the appendix does not rule out acute appendicitis 2. Most important reason for false negative is inexperience in GIUS & examination technique 3. Rectrocecal or pelvis position 4. Obesity 5. Focal appendicitis confined to the tip (5%)
STATEMENT 7 Atypical positions of the appendix are the most frequent cause of false-negative results. Consensus levels of agreement: A+ 12/18; A– 4/18; I 2/18
False-positive 1. Incorrect classification of terminal ileum as an inflamed appendix 2. Other tubular structures in RLQ: diverticulitis, dilated Fallopian tube … et al. 3. Appendiceal thickening due to othe conditions
STATEMENT 8 Systematic search for signs that suggest differential diagnoses of appendicitis should be implemented. Consensus levels of agreement: A+ 17/18; A– 1/18
Diagnostic accuracy: Sensitivity, specificity & accuracy > 90% (influenced by operator experience & patient characteristics) In equivocal pregnancy cases, MRI is considered the method of choice in pregnant women.
STATEMENT 9 In the hands of well-trained operators and with adequate equipment, the sensitivity and specificity of ultrasound in acute appendicitis are similar to CT and MRI. Consensus levels of agreement: A+ 15/18; A– 2/18; I 1/18
STATEMENT 10 In any case of suspected appendicitis, an “ultrasound first” strategy should be used in both children and adults. Consensus levels of agreement: A+ 18/18
STATEMENT 11 Complementary CT or MRI should be limited to inconclusive findings and difficult conditions, e. g. in very obese patients or in pregnant women (MRI). Consensus levels of agreement: A+ 14/18; A– 3/18; I 2/18; D– 1/18
STATEMENT 12 Structured training programs, quality controls and the use of standardized ultrasound reporting templates should be integrated in the training of emergency physicians for point-ofcare ultrasound (POCUS) in appendicitis. Consensus levels of agreement: A+ 17/18; D+ 1/18
Acute diverticulitis
STATEMENT 1 Ultrasound imaging should be a routine procedure in all patients with suspected diverticulitis. Consensus levels of agreement: A+ 17/18; I 1/18
STATEMENT 2 Sonography can confirm the diagnosis of acute diverticulitis and allows early risk stratification. Consensus levels of agreement: A+ 16/18; A– 1/18; I 1/18
Graded compression at the point of maximum tenderness pointed out by the patient 3 diagnostic criteria of acute diverticulitis 1. Short segmental colonic wall thickening (>5mm) 2. Demostration of the inflamed diverticulum in the wall-thickened area (Dome sign) 3. Pericolic tissue changes (non-compressible, hyperechoic)
STATEMENT 3 GIUS accurately assesses acute diverticulitis by detecting short segmental colonic wall thickening (> 5 mm), an inflamed diverticulum and pericolic tissue changes. Consensus levels of agreement: A+ 15/17; A– 2/17
STATEMENT 4 GIUS should be the first-line diagnostic procedure followed by additional CT scan only in the case of inconclusive sonographic findings. Consensus levels of agreement: A+ 13/18; A– 2/18; D– 2/18; D+ 1/18
STATEMENT 5 CEUS can be used in cases of acute diverticulitis to differentiate between periintestinal phlegmon and abscess. Consensus levels of agreement: A+ 18/18
STATEMENT 6 Ultrasound-guided puncture/drainage is the first-line option in the therapy of abscesses larger than 3 cm. Consensus levels of agreement: A+ 13/17; A– 3/17; D– 1/17
STATEMENT 7 Drainage of diverticular abscesses using the trocar technique single step) is easy to perform and is usually successful. Consensus levels of agreement: A+ 16/17; A– 1/17
STATEMENT 8 CEUS before intervention may be helpful to demonstrate the real extension of the abscess. Consensus levels of agreement: A+ 14/18; A– 1/18; I 2/18; D– 1/18
It must be clear that little experience with GIUS inevitably yields unsatisfactory results and it has been shown that less than 500 completed examinations is insufficient.
STATEMENT 9 GIUS and CT have proved to have similar sensitivity and specificity in the assessment of acute diverticulitis. Consensus levels of agreement: A+ 14/18; A– 2/18; D– 1/18; D+ 1/18
