Parasternal Long Axis (PLAX)

The PLAX view establishes the long axis of the heart but is generally not the optimal view to assess the right ventricle. Nonetheless, comparing the LA, Aortic root and RVOT, which should be roughly the same size, we note the RVOT is more than double the size of the other “chambers”.

Parasternal Short Axis (PSAX)

Chamber size comparison is best assessed with the PSAX view as was done here or the Apical 4 chamber (A4C) view. Here we again find a dilated right ventricle closest to the peaked footprint of the phased array probe. Not only is the RV dilated (greater than LV size), but right sided pressure is flattening the septum, giving the LV a characteristic “D-shaped” appearance. In A4C, TAPSE < 17mm is consistent with pulmonary hypertension.

Any patient with significant acute pulmonary hypertension will have a plethoric IVC. This IVC is > 3cm at the level of the hepatic veins with to and fro venous flow noted.

These findings clearly show pulmonary hypertension — the next step is to decide whether this hypertension is acute or chronic. Certainly factors other than echo findings will be important. What is the patient’s history, is there thrombus on CT, and are there any distinguishing features of their thrombus that suggest acute vs. chronic PE.

On Echo a few factors can be easily assessed:

• Right atrial size – RA > LA size suggests chronic pHTN.
• Right ventricular wall thickness
  • Measure the RV free wall at end-diastole, perpendicular to basal third, just below tricuspid valve. Best subxiphoid.
  • Chronic pHTN > 5 mm
  • Normal / Acute pHTN wall thickness:  $$≤ 5 mm
• More advanced techniques using spectral doppler assessment (TRPG, 60/60) are available as well.

For this patient with PE on CT and acute right ventricular failure, PERT and / or the ICU should see the patient sooner rather than later.

47 year old with no significant history apart from diverticulitis, presents with left flank pain similar to prior diverticular disease. Pain is of varying intensity. No hematuria. No dysuria. No fevers or chills. No vomiting or diarrhea.

In the ED he is comfortable and afebrile with normal vital signs.

ULTRASOUND

Point of care ultrasound at the point of maximal tenderness over the patient’s left upper quadrant/flank was performed with the large curvilinear transducer. The patient had tenderness to sonopalpation, with bowel wall edema greater than 0.5cm, enhancement of the pericolonic fat. No diverticula were noted. There was no surrounding fluid or hypoechoic collection to suggest abscess or perforation. These findings were suggestive of colitis.

Complicated diverticulitis would be indicated by: intraperitoneal free fluid, 2 or more areas of bowel wall edema in different abdominal quadrants, free air, presence of an abscess, or dilated loops of bowel greater than 2.5cm.

The (95% CI) test characteristics of POCUS in identifying diverticulitis, complicated diverticulitis, and colitis, as compared with CT findings, have been found to be:

• Sensitivity 0.92 (0.88–0.96)
• Specificity 0.97 (0.94–0.99)
• LR+ 30.67
• LR- 0.08

LABS

Labs are reassuring including WBC 8000 with no shift and a normal urinalysis.

MEDICATIONS

• 1000 cc of Normal Saline
• Oral and Intravenous Iohexol for CT
• Did not require analgesia in the ED

COMPUTED TOMOGRAPHY

A representative image below of his CT scan, shows: “mild/moderate wall thickening of the descending colon with mild surrounding inflammatory changes. No extraluminal air or rim-enhancing collection noted. This was interpreted as “descending colon colitis/diverticulitis without evidence of perforation or abscess.”

MANAGEMENT

Our past paradigm of outpatient diverticulitis management centered around antibiotic administration. In reviewing treatment for diverticulitis, the Cochrane Library Systematic Review reminds us that, “antibiotics can cause serious adverse effects, including life-threatening allergic reactions or super-infections of the intestine. Growing antibiotic resistance is an increasing problem rendering some infections impossible to treat with possible fatal outcomes. Therefore, strong arguments in favour of limiting the current use of antibiotics exist. Only three randomised controlled trials on the need of antibiotics are currently available and more are needed in order to obtain strong and reliable evidence. “ (Cochrane 2022)

Incorporating recent evidence into their guidelines, the American Gastroenterological Association (AGA 2015) recommends that “antibiotics should be used selectively, rather than routinely, in patients with acute uncomplicated diverticulitis. (qualifying that this is a conditional recommendation, with low quality of evidence).

Acknowledging that more evidence would be valuable, the 2022 Cochrane review, nonethless clarifies as follows:

the newest evidence shows that the use of antibiotics for the treatment of uncomplicated acute diverticulitis is not superior to treatments that do not include antibiotics.”

REFERENCES

Cochrane Library Systematic Review

AGA 2015

14 year old boy brought in by parents with abdominal pain. Pain was vague when it started yesterday. Today it is more persistently located in the right lower quadrant. The child has some nausea but no emesis. Temp of 100.8 °F. Exam reproduces RLQ tenderness but no rebound, no guarding.

No other concerning symptoms.

ULTRASOUND

You discuss your concern for appendicitis with his parents, order labs and then bring the ED ultrasound to the bedside. You begin by scanning the area of maximal discomfort with a linear probe but do not find any abnormalities. You bring the probe down to the iliac vessels and obtain this clip.

In this clip we see the iliac vessels on the right side in far field. The center of the image, in short axis, we see a tubular structure with hypoechoic walls lying over the psoas muscle.

Obtaining a long axis view of this structure we find that is blind, ending and non-compressible.

Measuring in short axis, we find that this structure has a diameter of 10 mm or 1 cm.

With a present history and exam consistent with appendicitis the finding of a 10 mm non-compressible, blind ending structure in the right lower quadrant makes appendicitis very likely.

MANAGEMENT

The on call general surgeon is notified and the patient is prepared for operative management.