Abdominal Pain POCUS

Hello everyone,

This case comes to us from one of our Ped’s EM Ultrasound fellows! Here is the case:

Teenage female with a history of Crohn’s s/p colectomy presents with worsening symptoms for the past 4 days including increasing colostomy output, abdominal tenderness, and NBNB emesis. Vital signs are stable. On physical exam there is mild distention of the abdomen but no rebound tenderness or guarding. POCUS revealed the attached images.

Questions for discussion:
• What probe is being used?
• What is your differential diagnosis? Are there findings on this clip that help suggest a particular diagnosis?
• How does this POCUS finding help with the clinical management?
• What are the limitations to POCUS for this condition?

Please post your comments to the blog. We will be sharing our answers/ teaching points next week (11/30/20).

Happy Thanksgiving,

-Christopher

Tags: 
abdominal pain, POCUS

 

Comments (2)

Karthik Vadamalai
says:

1. What probe is being used?- Curvilinear probe
2. What is your differential diagnosis? Are there findings on this clip that help suggest a particular diagnosis?- Bowel obstruction would be my top differential in this case. Findings-The bowel loops are filled contents and when peristalsis occurs the contents seem to move forward and immediately pushed backwards- indicating possible obstruction in the distal bowel segment.
3.How does this POCUS finding help with the clinical management?- Patient will need surgical consultation for bowel obstruction
4.What are the limitations to POCUS for this condition?- POCUS imaging alone cannot rule out bowel obstruction.

Hey everyone,

Here are the “results” for this case (from Dr. V Philip & I):
1. Curvilinear probe (curvilinear probe but is a high(er) frequency probe (9Mhz-3mHz) so we really like it for our peds abdominal exams. )
2. Ddx: SBO, ileus; positive findings: to & fro peristalsis. >2.5cm bowel diameter with fluid within
3. Increase throughput (speed of consults and admission); would place NG if +N/V while awaiting consults. Usually have high clinical suspicion of disease process based on HPI & exam and I think this would help confirm; some mixed studies of POCUS sensitivity here so would have low threshold to further workup a child w/ a complex PMH and story that fits (at least for now until further studies confirm sensitivity)
a. Becker BA, Lahham S, Gonzales MA, Nomura JT, Bui MK, Truong TA, Stahlman BA, Fox JC, Kehrl T. A Prospective, Multicenter Evaluation of Point-of-care Ultrasound for Small-bowel Obstruction in the Emergency Department. Acad Emerg Med. 2019 Aug;26(8):921-930. doi: 10.1111/acem.13713. Epub 2019 Mar 12. PMID: 30762916.
b. Frasure SE, Hildreth AF, Seethala R, Kimberly HH. Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department. World J Emerg Med. 2018;9(4):267-271. doi: 10.5847/wjem.j.1920-8642.2018.04.005. PMID: 30181794; PMCID: PMC6117534.
4. Though POCUS can suggest an obstruction, it cannot determine WHERE it is occurring (transition point), or why (ie a tumor/mass, stricture, hernia, etc) as limitations to its use. It also cannot rule OUT an obstruction.

Thank you for the Case, Dr. Philip!

-Christopher

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