Case of the month October 2024: Unusual neck lesion – CEUS as an aid to diagnosis
November 19, 2024
Lasse Kjær Nielsen1*, Samir Jawad1 , Camilla Wium Bjerrum1
1 Department of Radiology, Copenhagen University Hospital, Rigshospitalet, Denmark.
* Correspondence: lasse.kjaer.nielsen.01@regionh.dk
Clinical history
A 64-year-old female was found unconscious in her home and brought to the hospital. A brain CT showed hydrocephalus, due to a large fossa posterior meningioma and the patient underwent ventriculostomy. Two days later she was transferred to the neurointensive care unit as she had sepsis with elevated CRP (224 mg/L), low white blood cells (2.9 109/L) and hypotension. She also had an elevated serum amylase of 1410 U/L and distension of the abdomen with general tenderness. An ultrasound of the abdomen was requested due to a suspicion of pancreatitis and/or ascites.
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Question 1 of 3
1. Question
Question 1: What are the findings on the ultrasound images?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is: Heterogenic abdominal free fluid and normal flow in the portal vein
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q1 is: Heterogenic abdominal free fluid and normal flow in the portal vein
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Question 2 of 3
2. Question
Discussion
Figure 1 shows plenty of free fluid in the right and left upper quadrants surrounding the liver and spleen. The flow direction in the portal vein is normal. The free fluid has heterogenic echogenicity, suggesting protein content. As the pancreas is not shown in these images, we cannot determine if there are radiological signs of pancreatitis or not.
The following day the patient’s condition was unchanged with a tender abdomen and sepsis. The referring physician requested an ultrasound guided paracentesis of the abdomen.
Video 1: B-mode ultrasound, right iliac fossa.
Question 2: What are the findings on the ultrasound video?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q2 is: Small bubbles in the free fluid indicating free gas
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q2 is: Small bubbles in the free fluid indicating free gas
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Question 3 of 3
3. Question
Discussion
The video shows a large amount of heterogenic free fluid in the abdomen with several small hyperechoic foci. The small hyperechoic foci are gas bubbles travelling upwards in the free fluid indicating pneumoperitoneum.
Question 3: What is the next step?
Correct
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q3 is: You call the referring physician immediately and inform him/her about your findings and suggest that he/she consults with an abdominal surgeon.
Discussion
Pneumoperitoneum indicates a possible GI-perforation and you should inform the referring physician immediately and suggest that he/she consults with an abdominal surgeon. The patient’s situation will determine whether further imaging is needed or if the patient should go to theatre. Usually a contrast enhanced CT (CECT) is requested when there is a suspicion of free gas in the abdomen, but ultrasound has a high sensitivity of up to 95% when evaluated by physicians with at least 3 years of abdominal ultrasound experience(1).
In the presented case the referring physician consulted with an abdominal surgeon, who took the patient to the theatre without further diagnostic imaging. The free gas was caused by a perforated duodenal ulcer.
Additional Image
Figure 2: CECT of the abdomen 10 days after surgery shows pneumoperitoneum, a large amount of free fluid and a hematoma between the liver and the pancreas. Also there is a surgical drain with a reported high output.
Additional Discussion
Findings of the above amount of free gas and free fluid 10 days after surgery is unusual and there should be a high suspicion of reperforation of the ulcer, which was the case for the this patient. Reperforation of a perforated ulcer after initial surgery is reported to be around 5.4% (2).
Conclusion
When a patient presents with symptoms of GI-perforation the imaging gold standard is a CT of the abdomen. However, this may be impossible if the patient is unstable. Often the initial imaging modality in patients with abdominal pain is ultrasound. As spontaneous pneumoperitoneum may have a high clinical impact on patient management it is important to be familiar with and recognize the sonographic findings of free intraabdominal gas. In this case the free intraabdominal gas was dispersed between large amounts of free fluid providing a good sonographic window / visualization of the air bubbles. In other cases with less or no free fluid the sonographic findings differ and you may instead see a reverberation artefact, which can be small or large depending on the amount of free gas (3,4).
When scanning the abdomen, keep in mind that you may miss the important finding of free gas if you compress the abdomen too much with the transducer.
Conflicts of interest
The authors declare no conflict of interest
References
- Nazerian et al. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Critical Ultrasound J (2015) 7:15
- Byrne et al. Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study. BMJ Open. 2018 Aug 20;8(8):e023721.
- Jones R. Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain. Am J Emerg Med. 2007 Sep;25(7):838-41
- Khor M et al. Sonographic detection of pneumoperitoneum. BJR Case Rep. 2017 May 4;3(4)
Incorrect
CORRECT ANSWER EXPLAINED BELOW Correct answer to Q3 is: You call the referring physician immediately and inform him/her about your findings and suggest that he/she consults with an abdominal surgeon.
Discussion
Pneumoperitoneum indicates a possible GI-perforation and you should inform the referring physician immediately and suggest that he/she consults with an abdominal surgeon. The patient’s situation will determine whether further imaging is needed or if the patient should go to theatre. Usually a contrast enhanced CT (CECT) is requested when there is a suspicion of free gas in the abdomen, but ultrasound has a high sensitivity of up to 95% when evaluated by physicians with at least 3 years of abdominal ultrasound experience(1).
In the presented case the referring physician consulted with an abdominal surgeon, who took the patient to the theatre without further diagnostic imaging. The free gas was caused by a perforated duodenal ulcer.
Additional Image
Figure 2: CECT of the abdomen 10 days after surgery shows pneumoperitoneum, a large amount of free fluid and a hematoma between the liver and the pancreas. Also there is a surgical drain with a reported high output.
Additional Discussion
Findings of the above amount of free gas and free fluid 10 days after surgery is unusual and there should be a high suspicion of reperforation of the ulcer, which was the case for the this patient. Reperforation of a perforated ulcer after initial surgery is reported to be around 5.4% (2).
Conclusion
When a patient presents with symptoms of GI-perforation the imaging gold standard is a CT of the abdomen. However, this may be impossible if the patient is unstable. Often the initial imaging modality in patients with abdominal pain is ultrasound. As spontaneous pneumoperitoneum may have a high clinical impact on patient management it is important to be familiar with and recognize the sonographic findings of free intraabdominal gas. In this case the free intraabdominal gas was dispersed between large amounts of free fluid providing a good sonographic window / visualization of the air bubbles. In other cases with less or no free fluid the sonographic findings differ and you may instead see a reverberation artefact, which can be small or large depending on the amount of free gas (3,4).
When scanning the abdomen, keep in mind that you may miss the important finding of free gas if you compress the abdomen too much with the transducer.
Conflicts of interest
The authors declare no conflict of interest
References
- Nazerian et al. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Critical Ultrasound J (2015) 7:15
- Byrne et al. Short-term outcomes after emergency surgery for complicated peptic ulcer disease from the UK National Emergency Laparotomy Audit: a cohort study. BMJ Open. 2018 Aug 20;8(8):e023721.
- Jones R. Recognition of pneumoperitoneum using bedside ultrasound in critically ill patients presenting with acute abdominal pain. Am J Emerg Med. 2007 Sep;25(7):838-41
- Khor M et al. Sonographic detection of pneumoperitoneum. BJR Case Rep. 2017 May 4;3(4)