Month: January 2026

Posted on

Case 61: Detection of Abdominal Aortic Aneurysm Using Point-of-Care Ultrasound

Sanjana Sanghani, Gerald Tolbert, Rachna Subramony

A 52-year-old male with a past medical history significant for hypertension and hyperlipidemia presented to the Emergency Department with two days of intermittent chest discomfort accompanied by mild epigastric pain. The pain was non-radiating, episodic, and not associated with nausea, vomiting, diaphoresis, syncope, or exertion. He denied recent trauma, heavy lifting, or prior similar episodes. There was no known personal history of vascular disease, tobacco use, or family history of aneurysmal disease.

An electrocardiogram demonstrated normal sinus rhythm without ischemic changes.

Vital Signs: BP 148/92 mmHg | HR 78 | T 98.1°F | RR 18 | SpO2 98% on room air

The patient appeared comfortable and in no acute distress. Cardiopulmonary examination was unremarkable, with normal heart sounds and clear lung fields. Abdominal examination revealed mild tenderness to deep palpation in the epigastric region without guarding, rebound tenderness, or palpable pulsatile mass. No abdominal bruits were auscultated. Peripheral pulses were symmetric and intact in all extremities, and there were no focal neurologic deficits.

Given the patient’s nonspecific symptoms, elevated blood pressure, and underlying cardiovascular risk factors, a point-of-care abdominal aortic ultrasound was performed to evaluate for occult aortic pathology. Bedside ultrasound examination of the abdominal aorta was performed using a low-frequency (2–5 MHz) curvilinear transducer. The aorta was evaluated in both transverse and longitudinal planes from the epigastrium to the aortic bifurcation, with measurements obtained from outer wall to outer wall, as recommended by established ultrasound guidelines.

Figure 1: Focal aneurysmal dilation of the abdominal aorta, with maximal diameter exceeding 3.0 cm, consistent with an ectatic aorta/ abdominal aortic aneurysm.

No free intraperitoneal fluid was identified on the focused abdominal assessment.

Discussion

Abdominal aortic aneurysm (AAA) is defined as a focal dilation of the abdominal aorta measuring ≥3.0 cm in maximal diameter or greater than 50% of the expected normal diameter. AAAs are most commonly infrarenal and fusiform in morphology, though saccular aneurysms—characterized by asymmetric outpouching—are less common and may be associated with higher rupture risk depending on etiology and size.

Point-of-care ultrasound (POCUS) is a highly effective, rapid, and noninvasive modality for the detection of AAA in the emergency department. Numerous studies have demonstrated that emergency physician–performed ultrasound has a sensitivity approaching 99% and specificity of approximately 98% for identifying AAA. This high diagnostic accuracy makes POCUS a first-line imaging tool, particularly in patients with atypical presentations, vague abdominal or chest symptoms, or when rapid risk stratification is required.

Importantly, AAA can present with nonspecific symptoms such as epigastric pain, back pain, or chest discomfort, and classic findings, such as hypotension or a palpable pulsatile mass, are often absent. Early identification using bedside ultrasound allows for prompt vascular surgery consultation and expedited confirmatory imaging, typically with CT angiography in hemodynamically stable patients.

Ultrasound evaluation focuses on identifying aneurysmal dilation, assessing morphology, and measuring maximal diameter. The presence of mural thrombus, commonly seen within AAAs, does not by itself indicate rupture but may be associated with embolic complications. While POCUS excels at identifying aneurysm presence and size, it has limitations: it cannot reliably assess suprarenal extension, branch vessel involvement, or small contained ruptures. Additionally, ultrasound is not sufficient to exclude acute aortic dissection or retroperitoneal hemorrhage, for which CT angiography remains the gold standard.

In this case, although the patient was hemodynamically stable and lacked classic symptoms of rupture, bedside ultrasound facilitated early recognition of significant aortic pathology that may have otherwise been delayed due to the nonspecific nature of his presentation.

Conclusion

This case underscores the critical role of point-of-care ultrasound in the emergency evaluation of patients with vague chest or abdominal symptoms and cardiovascular risk factors. Rapid bedside identification of an abdominal aortic aneurysm enabled early diagnosis, appropriate risk stratification, and timely specialty referral. POCUS remains an indispensable diagnostic adjunct in emergency medicine, particularly for the detection of life-threatening aortic pathology.

References

  1. Tayal VS, Graf CD, Gibbs MA. Prospective Study of Accuracy and Outcome of Emergency Ultrasound for Abdominal Aortic Aneurysm. Acad Emerg Med. 2003;10(8):867–871. doi:10.1197/aemj.10.8.867
  2. Society for Vascular Surgery. Practice Guidelines for the Management of Abdominal Aortic Aneurysms. J Vasc Surg. 2018;67(1):2–77. doi:10.1016/j.jvs.2017.10.044
  3. Jang T, Docherty G, Aubin C, et al. Point-of-Care Ultrasound for the Detection of Abdominal Aortic Aneurysm in the Emergency Department. Ann Emerg Med. 2020;75(4):534–542. doi:10.1016/j.annemergmed.2019.09.002
  4. Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery Practice Guidelines on the Care of Patients with an Abdominal Aortic Aneurysm. J Vasc Surg. 2018;67(1S):2S–77S.e2. doi:10.1016/j.jvs.2017.10.044
Posted on

Case 60: A Stubborn Sore Throat: Insights through Ultrasound

Sneha Thandra, Anthony Medak

Case: A 19 year old female with a history of palpitations, shortness of breath, and syncope presents to the ED with throat pain with swelling for 3 weeks. The pain was noted to be bilateral, worsened with swallowing, but she was able to tolerate some oral intake. Patient had previously been seen on multiple occasions in ED/Urgent Care and had received dexamethasone without significant relief. She had not received antibiotics. Denied fevers or cough and had no PMH or known allergies. 

Vitals: BP 127/90 | Pulse 103 | Temp 98.2 °F (36.8 °C) | Resp 16 | Wt 58.1 kg (128 lb) | SpO2 100% 

On exam she is not in acute distress, her mucous membranes are moist. She phonates normally. There is slight peritonsillar fullness and an enlarged tonsil with notable tonsillar exudate on the right. No trismus or uvular deviation noted. The rest of her exam was normal.

Labs: WBC 22k

Images: Linear probe - Ultrasound Neck

Figure 1: Transcervical ultrasound of R peritonsillar abscess. Note highlighted hypoechoic material within parenchyma of tonsil.
Figure 2: Transcervical ultrasound of R peritonsillar abscess, with no flow evident on Doppler.
Video 1: Note the hypoechoic signal within the tonsil parenchyma.

ED Course: CT neck with contrast obtained revealed advancing tonsillitis with a right-sided tonsillar abscess. Abscess drainage attempted at bedside, but no purulence was obtained. The patient was given analgesic support (ketorolac and dexamethasone), IV fluids, and started on antibiotics (cefpodoxime and clindamycin). A referral to ENT was placed, and given that the patient was stable with no airway compromise, she was discharged with outpatient management.

Discussion: 

Peritonsillar abscesses (PTA) can form secondary to tonsillitis.

PTA is a common ED diagnosis (about 1 in 10,000 patients) that is a perfect application of point-of-care ultrasound (POCUS). Given the increased availability of POCUS in most ED/Urgent Care settings, the utility of a rapid and noninvasive imaging modality to evaluate for PTA can facilitate timely management, differentiate from cellulitis, and reduce the need for unnecessary CT imaging. This case illustrated the utility of POCUS in a 19 year old female with 3 weeks of persistent throat pain, where POCUS revealed an abnormal tonsil with a loculated anechoic fluid collection. Complications from PTA include airway obstruction, retropharyngeal abscess, among others. 

Although classic features of fever, sore throat, dysphagia, trismus, and “hot potato” voice can help with clinical diagnoses, overlapping features with other conditions including peritonsillar cellulitis, requires a tool with good sensitivity and specificity. Physical exam is noted to have a sensitivity and specificity of approximately 75% and 50%, respectively. However, a systematic review analyzing 18 studies from 1992 to 2021 that involved a total of 541 patients with PTA for a meta-analysis, found that POCUS has a sensitivity of about 74% and specificity of 79%. On subgroup analysis, although no significant difference was found between intraoral vs transcervical approaches (Figure 5), intraoral had a higher sensitivity (91% vs 80%) and transcervical had a higher specificity (81% vs 75%).1 Another study utilizing retrospective chart review found that POCUS reduced ED length of stay for patients: average of 160 minutes vs 293 minutes for patients where US was used compared to patients where US was not used. Specifically, after reviewing 58 charts, they found that 0% of patients diagnosed with ultrasound were admitted to the hospital, while 36.4% of patients where US was not used were admitted.2 

Beyond diagnosis, POCUS can assist in PTA treatment, improving aspiration outcomes. One study comparing US-guided versus non US-guided aspiration identified a success rate of 99% with POCUS and 80.3% without. In addition, ENT consultation rate was 12.9% with POCUS vs. 66% without POCUS use.3,4 Overall, POCUS offers advantages in evaluation of tonsillar cellulitis/PTA, while improving rates of successful aspiration, reducing unnecessary CT imaging, and thereby decreasing ED LOS. 

Figure 3: Demonstration of transoral (A) vs. transcervical (D) POCUS techniques. Panel B and E represent a normal tonsil. Panel C and F represent an abnormal tonsil with a loculated anechoic fluid collection. (*)indicates PTA, T indicates tonsil, S indicates submandibular gland (Kim et al., 2023).

References:  

  1. Kim DJ, Burton JE, Hammad A, Sabhaney V, Freder J, Bone JN, Ahn JS. Test characteristics of ultrasound for the diagnosis of peritonsillar abscess: A systematic review and meta-analysis. Acad Emerg Med. 2023 Aug;30(8):859-869. doi: 10.1111/acem.14660. Epub 2023 Jan 30. PMID: 36625850.
  2. Bryczkowski C, Haussner W, Rometti M, Wei G, Morrison D, Geria R, Mccoy JV. Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess. Cureus. 2022 Dec 5;14(12):e32207. doi: 10.7759/cureus.32207. PMID: 36620852; PMCID: PMC9812542.
  3. Gibbons RC, Costantino TG. Evidence-Based Medicine Improves the Emergent Management of Peritonsillar Abscesses Using Point-of-Care Ultrasound. J Emerg Med. 2020 Nov;59(5):693-698. doi: 10.1016/j.jemermed.2020.06.030. Epub 2020 Aug 19. PMID: 32826122.
  4. Costantino TG, Satz WA, Dehnkamp W, Goett H. Randomized trial comparing intraoral ultrasound to landmark-based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg Med. 2012 Jun;19(6):626-31. doi: 10.1111/j.1553-2712.2012.01380.x. PMID: 22687177.
Posted on

Case 59: Abdominal and Pelvic Pain

Eli Tran, Elaine Yu

20YO female presented to the emergency department with 4-5 days of pelvic/abdominal pain, with abrupt worsening one day prior while resting. Her pain was sharp, sudden, and improved with ED analgesics. No dizziness, lightheadedness, or vaginal bleeding. LMP 4 weeks prior. She was not using birth control.

Exam: Vital signs were within normal limits. She appeared uncomfortable but non-toxic. She had pelvic and lower abdominal tenderness without guarding or rebound. No focal cardiopulmonary or neurologic abnormalities.

Labs

  • WBC 14.6 to 18.7 with neutrophilia.
  • Hgb 11.3
  • hCG <1.
  • Lactate 1.4.
  • Coags normal.
  • UA: SG 1.042, ketonuria, mild proteinuria; no hematuria.

Bedside pelvic ultrasound was performed with the following images:

Figure 1: Transabdominal ultrasound with free fluid in the pelvic region.

Figure 2: Transvaginal ultrasound with pelvic free fluid.

Figure 3: Transvaginal ultrasound with two cystic structures in the area of the left ovary.

ED Course

A formal pelvic ultrasound was ordered.

Figure 4: Pelvic free fluid with irregular cystic structure in area of left ovary consistent with a hemorrhagic cyst.

A CT scan of the abdomen and pelvis was ordered for concern of active hemorrhage. The CT showed showed a ruptured hemorrhagic ovarian cyst without active bleeding. There was also a finding of an absent left kidney with compensatory hypertrophy of the right kidney.

The patient remained hemodynamically stable and responded to analgesia. Her repeat hemoglobin after several hours was 12.4. Gynecology was consulted and recommended conservative management with 6-8 week follow-up.

The solitary kidney was an incidental finding unrelated to the current presentation. There was no hydronephrosis, obstruction, or infection. Renal function was preserved.

Discussion

The patient’s clinical picture and imaging are most consistent with a ruptured hemorrhagic ovarian cyst, a common cause of sudden pelvic pain with hemoperitoneum in reproductive-age women. Hemodynamic stability and absence of active bleeding support conservative management.

The incidentally detected solitary kidney is important to document but does not alter acute ED management. Most solitary kidneys identified incidentally in emergency imaging are congenital1-3 (unilateral renal agenesis or multicystic dysplastic kidney) or acquired (post-nephrectomy for tumor, trauma, or severe infection). Congenital solitary kidney accounts for the majority of incidental cases, often presenting with compensatory hypertrophy of the remaining kidney, as seen here.

Solitary kidney is associated with an increased long-term risk of CKD and hypertension, with some studies demonstrating >3-fold increased risk compared to individuals with two kidneys. The risk is highest in patients with vesicoureteral reflux or ureteropelvic junction obstruction, which occur in 17–48 percent of congenital cases. Cross-sectional imaging4-5 is generally sufficient for identifying and characterizing a solitary kidney; additional imaging (e.g., nuclear scintigraphy) is rarely required unless ectopic tissue or uncertain anatomy is suspected.

ED disposition: home with Gynecology and Nephrology follow-up

References

  1. Kim S, Chang Y, Lee YR, et al. Solitary Kidney and Risk of Chronic Kidney Disease. Eur J Epidemiol. 2019;34(9):879-888.
  2. Westland R, Schreuder MF, van Goudoever JB, et al. Clinical Implications of the Solitary Functioning Kidney. CJASN. 2014;9(5):978-986.
  3. Urisarri A, Gil M, Mandiá N, et al. Risk Factors for CKD in Congenital Solitary Kidney. Medicine. 2018;97(32):e11819.
  4. Krill A, Cubillos J, Gitlin J, Palmer LS. Abdominopelvic Ultrasound as a Diagnostic Tool for Solitary Kidney. J Urol. 2012;187:2201-2204.
  5. Grabnar J, Rus RR. Is Renal Scintigraphy Necessary in Diagnosis of Congenital Solitary Kidney? Pediatr Surg Int. 2019;35:729-735.
Translate »