Case 78: Seizure-Associated Takotsubo Syndrome Complicated by Suspected Left Ventricular Thrombus and Multifocal Ischemic Stroke

Matthew Van Ligten, Bryan Merte

A 52-year-old woman with epilepsy treated with levetiracetam and lamotrigine, hypertension, and non-Hodgkin lymphoma previously treated with chemotherapy and in remission presented after being found confused and incontinent of urine. Her daughter found her staring blankly after being unable to reach her by phone for approximately one hour.

As the patient remained postictal and was a limited historian, additional history was obtained from emergency medical services. Paramedics had been called for what appeared to be one of her typical seizures with prolonged confusion. They subsequently witnessed a second episode of blank staring in the ambulance followed by extensor posturing, which resolved prior to medication administration after approximately two minutes.

There was no reported head trauma or infectious prodrome and no known cardiopulmonary disease. Chart review showed an outside hospitalization several months earlier for sepsis secondary to pneumonia; her prior lymphoma treatment regimen was not available in the records, though a recent formal echocardiogram was unremarkable.

The patient was comfortable appearing and in no acute distress. Respiratory effort and breath sounds were normal, as were heart rate and rhythm. She was alert and oriented to person and place but not year, with impaired attention. She was drowsy but demonstrated no focal cranial nerve, motor, sensory, or coordination deficits.

Test	Result
White blood cell count	20.4 × 10³/µL
Absolute neutrophil count	17.3 × 10³/µL
Hemoglobin	14.1 g/dL
Platelets	512 × 10³/µL
Sodium	134 mmol/L
Creatinine	1.01 mg/dL
Glucose	299 mg/dL
Lactate	2.5 mmol/L

**Image 1.** Initial chest radiograph showing patchy and hazy left-lung opacities, interpreted as possible pneumonia or asymmetric pulmonary edema.

Approximately 60 minutes after ED arrival, the patient had another staring spell concerning for recurrent seizure. During the episode, her oxygen saturation fell into the low 70s with a reliable waveform and associated lip cyanosis. The episode resolved before benzodiazepine administration. Serial reassessments over the next 30 minutes showed progressive tachycardia, hypertension, and hypoxemia.

Vital sign	Value
Blood pressure	205/145 mm Hg
Heart rate	146 beats/min
Respiratory rate	26 breaths/min
Temperature	36.7°C
Oxygen saturation	93% on 2 L/min nasal cannula

She appeared ill and agitated with mildly increased work of breathing. Electrocardiography demonstrated sinus tachycardia without ST-segment elevation or other acute ischemic changes. Initial troponin was 424 ng/L (reference <51 ng/L).

A bedside ultrasound of the heart and lungs was performed.

Video 1. Cardiac POCUS demonstrating severe left ventricular systolic dysfunction with relative basal hyperkinesis.

Video 2. Additional cardiac POCUS demonstrating left ventricular systolic dysfunction, a normal-sized right ventricle, and no interventricular septal flattening.

Video 3. Lung POCUS demonstrating multiple B-lines consistent with pulmonary interstitial syndrome.

**Image 2.** Chest radiograph obtained after deterioration showing progression to bilateral interstitial and alveolar pulmonary edema.

Emergency Department Course

The patient received intravenous levetiracetam while CT of the head, CT angiography of the head and neck, and CT pulmonary angiography were obtained to investigate structural, vascular, and cardiopulmonary causes. Because the history remained limited and the differential included recurrent pneumonia, aspiration, and central nervous system infection, a broad infectious and metabolic evaluation was initiated. Lumbar puncture was deferred because of clinical instability, and empiric vancomycin, ampicillin, and ceftriaxone were administered. Before cardiopulmonary decompensation, while her vital signs were normal, she received a total of 1 L of intravenous crystalloid.

After cardiac and lung POCUS raised concern for Takotsubo syndrome with cardiogenic pulmonary edema, no additional large-volume crystalloid was administered. Treatment included intravenous furosemide, nitroglycerin, supplemental oxygen, and metoprolol 5 mg IV ×2. Metoprolol was used for severe-range hypertension and tachycardia after clinically significant LV outflow tract obstruction was considered unlikely on POCUS. Heart rate and blood pressure improved without observed hypotension, bradycardia, or another adverse effect. Because nitroglycerin and other interventions were given concurrently, the improvement cannot be attributed to metoprolol alone.

Noninvasive positive-pressure ventilation was deferred because the oxygen requirement remained modest and airway protection was a concern during the postictal period. The patient was admitted to the intensive care unit for recurrent seizure or possible nonconvulsive status epilepticus, acute hypoxemic respiratory failure, and severe left ventricular systolic dysfunction.

Hospital Course and Outcome

During admission, NT-proBNP resulted at 19,459 pg/mL, and troponin peaked at 2,259 ng/L. Formal transthoracic echocardiography demonstrated an LVEF of 19%, regional wall-motion abnormalities consistent with Takotsubo syndrome, and a possible apical LV thrombus. Therapeutic anticoagulation was started empirically.

Coronary CT angiography showed moderate stenosis of the first diagonal branch with otherwise mild plaque burden. Lesion-specific CT-derived fractional flow reserve indicated a low likelihood of flow limitation. No LV thrombus was visualized on coronary CT angiography or subsequent contrast-enhanced echocardiography.

Serial imaging showed rapid recovery of systolic function: LVEF improved from 19% to 54% on early repeat echocardiography and to 66% within 48 hours. The characteristic wall-motion pattern, prior documentation of normal systolic function, absence of a flow-limiting coronary lesion, and rapid recovery strongly supported Takotsubo syndrome. Invasive coronary angiography was therefore deferred.

Video 4: Repeat echocardiogram showing improvement of LV systolic function.

The neurologic presentation was characterized as possible nonconvulsive status epilepticus. EEG showed possible epileptiform discharges, although no further clinical seizure-like episodes occurred. Brain MRI demonstrated acute left parietal and left paramedian frontal infarcts. The stroke service considered the multifocal distribution most consistent with a cardioembolic mechanism in the setting of the suspected apical thrombus and initial LVEF of 19%.

Because the patient had recovery of her systolic function and neither contrast-enhanced echocardiography nor coronary CT angiography confirmed a persistent thrombus, therapeutic anticoagulation was discontinued in favor of antiplatelet therapy. The patient was discharged home on aspirin with family support at her neurologic baseline.

Discussion

Takotsubo syndrome is an acute heart failure syndrome characterized by transient regional LV dysfunction. The classic pattern consists of apical and midventricular hypokinesis or akinesis with relative basal hyperkinesis, though other variants occur. While regional dysfunction generally extends beyond a single coronary artery distribution, alternative causes of myocardial injury such as culprit coronary lesions must still be excluded before formal diagnosis.^1,2

Acute neurologic disease is a recognized physical trigger, and seizures are among the most frequently reported neurologic precipitants. These patients may not report chest pain or dyspnea, so the diagnosis can be overlooked when the initial evaluation is dominated by altered mental status or seizure activity.³ In this case, the causation between seizure activity, multifocal ischemic stroke, and cardiac dysfunction could not be definitively established; therefore, the diagnosis is most accurately represented by seizure-associated Takotsubo syndrome.

POCUS cannot independently distinguish Takotsubo syndrome from acute coronary occlusion, and B-lines are not specific to cardiogenic edema. However, immediate recognition of severe LV dysfunction with a characteristic regional pattern, combined with diffuse B-lines, rapidly shifted the working diagnosis toward cardiogenic pulmonary edema. This led the team to withhold additional crystalloid, begin diuresis and afterload reduction, and advocate for the appropriate level of care for stabilization and definitive cardiac testing. The case does not establish that the initial liter of crystalloid caused the deterioration or that additional fluid would necessarily have caused harm.

Evidence for beta-blockers in Takotsubo syndrome remains observational and conflicting. Expert consensus considers beta-blockade reasonable in selected hemodynamically stable patients until LV recovery, with cautious use in acute severe heart failure, hypotension, bradycardia, and marked QTc prolongation.⁴ A recent registry analysis associated beta-blocker therapy at discharge with lower long-term mortality but not reduced recurrence or faster LVEF recovery.⁵ There is no randomized evidence establishing benefit from acute IV beta-blockade. The observed improvement after metoprolol in this case should therefore be reported as a clinical course observation rather than evidence of efficacy.

Severe apical dysfunction can promote LV thrombus formation and systemic embolization.⁶ The first formal echocardiogram raised concern for an apical thrombus and prompted empiric anticoagulation, while MRI showed multifocal cerebral infarcts. However, neither contrast echocardiography nor coronary CT angiography later confirmed the thrombus. The case therefore illustrates a suspected cardioembolic complication rather than a definitively demonstrated LV thrombus.

The rapid recovery from an LVEF of 19% to 66% within 48 hours, together with prior normal systolic function, favored the diagnosis of transient stress cardiomyopathy. Initial severe systolic dysfunction identified a high-risk phenotype, even though ventricular function recovered quickly.^7,8

Bottom Line

In patients with seizure or altered mental status who develop unexplained tachycardia, hypoxemia, elevated cardiac biomarkers, or pulmonary edema, combined cardiac and lung POCUS can rapidly identify severe ventricular dysfunction and pulmonary congestion. The examination can guide early stabilization and level-of-care decisions while definitive coronary and cardiac evaluation proceeds. Severe transient apical dysfunction should also prompt evaluation for LV thrombus and systemic embolic complications.

References

1. Medina de Chazal H, Del Buono MG, Keyser-Marcus L, et al. Stress cardiomyopathy diagnosis and treatment: JACC state-of-the-art review. J Am Coll Cardiol. 2018;72(16):1955-1971. doi:10.1016/j.jacc.2018.07.072

2. Singh T, Khan H, Gamble DT, et al. Takotsubo syndrome: pathophysiology, emerging concepts, and clinical implications. Circulation. 2022;145(13):1002-1019. doi:10.1161/CIRCULATIONAHA.121.055854

3. Cammann VL, Scheitz JF, von Rennenberg R, et al. Clinical correlates and prognostic impact of neurologic disorders in Takotsubo syndrome. Sci Rep. 2021;11(1):23555. doi:10.1038/s41598-021-01496-9

4. Ghadri JR, Wittstein IS, Prasad A, et al. International expert consensus document on Takotsubo syndrome (part II): diagnostic workup, outcome, and management. Eur Heart J. 2018;39(22):2047-2062. doi:10.1093/eurheartj/ehy077

5. Raposeiras-Roubin S, Santoro F, Arcari L, et al. Beta-blockers and long-term mortality in Takotsubo syndrome: results of the multicenter GEIST Registry. JACC Heart Fail. 2025;13(5):815-825. doi:10.1016/j.jchf.2024.11.015

6. Ding KJ, Cammann VL, Szawan KA, et al. Intraventricular thrombus formation and embolism in Takotsubo syndrome: insights from the International Takotsubo Registry. Arterioscler Thromb Vasc Biol. 2020;40(1):279-287. doi:10.1161/ATVBAHA.119.313491

7. Citro R, Radano I, Parodi G, et al. Long-term outcome in patients with Takotsubo syndrome presenting with severely reduced left ventricular ejection fraction. Eur J Heart Fail. 2019;21(6):781-789. doi:10.1002/ejhf.1373

8. Almendro-Delia M, Lopez-Flores L, Uribarri A, et al. Recovery of left ventricular function and long-term outcomes in patients with Takotsubo syndrome. J Am Coll Cardiol. 2024;84(13):1163-1174. doi:10.1016/j.jacc.2024.05.075

August 19, 2026August 17, 2026

Case 77: Pleural Line Irregularities: Ultrasound in the Diagnosis of Possible Malignancy

Olivia Yale, Colleen Campbell

A 40-year-old male with no pertinent past medical history apart from significant cigarette use presented to the emergency department, referred from urgent care, for SOB and outside CXR concerning for a large right pleural effusion. The patient stated that over the past two months, he has had increasing SOB, coughing fits, and a 20-lb weight loss. The patient was born in Costa Rica but has lived in the United States for most of his life and is fully vaccinated. He denied any recent viral illness, recent travel, sick contacts, fever, abdominal pain, rashes, or chemical exposures. He stated that he has been smoking a pack of cigarettes a day for the past seven years and also occasionally smokes marijuana.

Vital Signs: BP 111/78, HR 96, RR 23, SpO2 94% on RA, T 98.3 F

Physical exam:
GEN: Thin, answering all questions appropriately
CV: RRR, no m/r/g, normal S1 and S2, peripheral pulses 2+ and equal in all extremities, no pedal edema
PULM: Diminished breath sounds throughout all right lung fields, mild rhonchi in the base of the left lung, no respiratory distress. Shallow breaths
EXT: No edema, no cords

Given the patient’s shortness of breath, urgent care CXR findings, and history, a bedside ultrasound was performed to further differentiate the patient’s complaint.

Figure 1. Right anterior lung/pleural ultrasound clip. Appropriate lung sliding (“ants marching in a line”), so less concern for pneumothorax. Multiple pleural line irregularities seen.

**Figure 2.** Right anterior lung/pleural ultrasound labeled. Notable pleural line irregularities.

Figure 3. Right posterior lung ultrasound clip for pocket evaluation prior to bedside thoracentesis. Large pleural effusion seen.

**Figure 4.** Near-complete opacification of the right hemithorax with small area of aeration in the right upper lobe. Nodular opacities scattered throughout the bilateral lungs which raise concern for large right-sided pleural effusion with severe pulmonary edema. Other etiologies not excluded.

Labs: WBC 7.5, Hb 14.3, PLT 330, Procal .04, Na 140, Cr .75, viral swab negative, lactate 1.1.

ED Course

In the ED, labs were collected (as above) and were largely unremarkable with no evidence of leukocytosis, anemia, or significant electrolyte abnormalities. After confirmation of a safe pocket with ultrasound, a bedside diagnostic and therapeutic thoracentesis was completed. After the thoracentesis, he was placed on 2L NC, but otherwise his vitals remained stable. CT chest showed a likely malignant pleural effusion and near-complete right lung collapse. He was admitted to internal medicine and was ultimately diagnosed with de novo metastatic adenocarcinoma of the lung.

Discussion

This case highlights the utility of pleural POCUS in the evaluation of lung pathology. The differential diagnosis for a young patient presenting with shortness of breath, weight loss, and a pleural effusion on outside imaging is broad, including malignancy, infection, fibrotic changes, trauma, autoimmune, and fluid overload/heart failure. However, in this patient with no prior medical conditions, no history of trauma, no fever or leukocytosis, and no other signs of fluid overload, new malignancy is of greatest concern, especially in the setting of weight loss and chronic tobacco use^1-4.

Lung POCUS is most commonly used to evaluate for a pneumothorax as part of the E-FAST exam. In this setting, the linear transducer is placed on the patient’s anterior chest, and the pleural line is evaluated for lung sliding, which is commonly referred to as “ants marching in a line”. Lung POCUS is also commonly utilized for evaluation for pleural effusions and in preparation for thoracentesis^2,5. This case highlights the importance of not only evaluating for lung sliding when doing a pleural line ultrasound, but also looking for pleural line irregularities, which are any disruption of the continuity of the pleural line, as well as for subpleural consolidations, which are small areas of lung tissue solidification just underneath the pleura. In healthy lung tissue, the pleural line is a smooth, thin (less than 3 mm), contiguous, hyperechoic line. The pleura consists of the inner visceral pleura layer that lines the lung and the outer parietal pleura that lines the chest wall, diaphragm, and mediastinum. Pleural line irregularities are seen on POCUS as fragmentation of the pleural line, often seen as “bumps”, “jaggedness”, or “dips”. The differential diagnosis for pleural line irregularities seen on POCUS includes infection (pneumonia, ARDS, TB), inflammation (post-COVID, pneumonitis), interstitial lung disease/fibrosis, and malignancy (mass, pulmonary nodules, mesothelioma). Irregularities of the pleura can also be due to subpleural consolidations caused by pneumonia, malignancy, infarction, or nodules^1,3,4,5. Although the differential for pleural irregularities seen on ultrasound is broad, in this given clinical scenario, the pleural line irregularities and subpleural consolidations seen in this patient are most likely secondary to underlying pulmonary nodules/metastatic disease in the setting of lung cancer. Ultrasound was also utilized in this case to identify a pocket for thoracentesis.

Ultrasound-guided thoracentesis is associated with substantially lower complication rates than the traditional anatomic landmark technique, particularly with respect to pneumothorax, as seen in a meta-analysis of three randomized controlled trials. In the meta-analysis, overall complications occurred in 7.4% of ultrasound-guided procedures compared with 26.0% using landmark guidance, while pneumothorax occurred in only 1.0% (1/99) of ultrasound-guided procedures versus 17.7% (20/113) with the landmark technique. Although hemorrhagic complications were too infrequent to compare (no bleeding events were reported in the single study assessing hemorrhage), the authors note that ultrasound guidance allows visualization of the diaphragm and surrounding anatomy, helping operators avoid inadvertent puncture of the intercostal artery and adjacent organs such as the liver and spleen, thereby reducing the risk of bleeding and solid-organ injury⁶.

Another prospective observational study evaluated the effectiveness and safety of real-time transthoracic ultrasound (TUS)-guided thoracentesis in 361 consecutive patients with pleural effusions. The procedure was successful in all cases, with ultrasound used continuously to visualize the needle and surrounding structures during fluid drainage. The technique demonstrated a very low complication rate, with only 3 pneumothoraces (0.83%) and no failed procedures. The authors note that traditional landmark-based thoracentesis has reported pneumothorax rates of 8.9–10.3%, whereas ultrasound-guided techniques generally reduce this to 0.97–4.9%. Real-time ultrasound guidance also helps avoid injury to adjacent structures, including the lung, diaphragm, liver, spleen, and intercostal vessels, thereby reducing the risk of bleeding and other procedural complications⁷.

Overall, lung POCUS and evaluation for pleural line irregularities are helpful in evaluating lung-related complaints and narrowing your differential diagnosis^2,3,5. Here, we demonstrate the utilization of bedside lung ultrasound, in conjunction with history and physical exam, in the evaluation and diagnosis of pleural pathologies and pleural effusions.

References

Deep Breathe. Pleural pathologies in lung ultrasound. Deep Breathe AI. Accessed June 4, 2026. https://deepbreathe.ai/blog/pleural-pathologies-lung-ultrasound
Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol. 2015;41(2):351-365. doi:10.1016/j.ultrasmedbio.2014.10.002
Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012;38(4):577-591. doi:10.1007/s00134-012-2513-4.
Boccatonda A, Cocco G, D’Ardes D, Delli Pizzi A, Vidili G, De Molo C, Vicari S, Serra C, Cipollone F, Schiavone C, et al. Infectious Pneumonia and Lung Ultrasound: A Review. Journal of Clinical Medicine. 2023; 12(4):1402. https://doi.org/10.3390/jcm12041402
Bhoil R, Ahluwalia A, Chopra R, Surya M, Bhoil S. Signs and lines in lung ultrasound. J Ultrason. 2021;21(86):e225-e233. doi:10.15557/JoU.2021.0036
Lakkadghatwala R, Wilson A, Sabhaney V, et al. Ultrasound guidance compared to anatomic landmark approach for thoracentesis: a systematic review and meta-analysis. Am J Emerg Med. 2025;97:159-164. doi:10.1016/j.ajem.2025.07.049. (sciencedirect.com)
Sperandeo M, Quarato CMI, Squatrito R, Fuso P, Dimitri L, Simeone A, Notarangelo S, Lacedonia D. Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis. Diagnostics (Basel). 2022 Mar 16;12(3):725. doi: 10.3390/diagnostics12030725. PMID: 35328278; PMCID: PMC8946970.

August 18, 2026August 17, 2026

Case 76: Point-of-Care Ultrasound Diagnosis of Prepatellar Bursitis in the Emergency Department

A. Elashmawy, B. Merte, and A. J. Medak

Chief Complaint: Left knee pain and swelling

History of Present Illness
A 63-year-old male with a past medical history of hypertension and diabetes presented with five days of progressive left knee swelling, redness, and discomfort. Symptoms were localized to the midline area inferior to the patella. The patient described worsening swelling, warmth, and tenderness to palpation in the area. He denied fever, recent trauma, or prior similar episodes. The patient had recently been prescribed trimethoprim-sulfamethoxazole, but he had not started taking the medication as of yet.

Vitals BP 134/79 | HR 84 | Temp 98.9°F (37.2°C) | RR 17 | SpO₂ 97% on RA

Physical Exam
Gen: Patient alert and in no distress, well-appearing.
Skin: Skin warm. Capillary refill less than 2 seconds.
Extremities: Neurovascularly intact in all four extremities. Examination of the left lower extremity revealed an approximately 6 cm × 6 cm area of fluctuance, erythema, warmth, and tenderness several centimeters inferior to the patella in the midline. Inferior to this area, there was diffuse mild swelling with faint erythema and warmth. Compartments were soft and nontender. Left knee noted to have minimal pain with active ROM. ROM was full.

Laboratory Studies:
- WBC: 12.4 ×10³/mm³ (elevated)
- ESR: 27 mm/hr (minimally elevated)
- CRP: 3.76 mg/dL (elevated)
Additional labs, including CMP and coagulation studies, were otherwise unremarkable.

Figure 1. POCUS of the anterior knee in transverse view, demonstrates a cobblestone appearance of the subcutaneous tissue (arrows) overlying the patellar tendon (green shaded area), consistent with surrounding cellulitis and superficial infrapatellar bursitis.

Figure 2. POCUS of the anterior knee in transverse view, demonstrates a hypoechoic fluid collection (arrows) overlying the patellar tendon, consistent with an infrapatellar bursal effusion. Color Doppler within the region of interest demonstrates no significant flow signal, consistent with a non-vascular fluid collection.

Figure 3. Axial CT of the left knee with IV contrast demonstrating a rim-enhancing fluid collection (arrows) overlying the patellar tendon, consistent with superficial infrapatellar bursitis. No imaging evidence of deep-space infection, septic arthritis, or osteomyelitis is identified.

ED Course
- Treatments and interventions: Intravenous vancomycin and ceftriaxone were administered. Ultrasound-guided aspiration of the infrapatellar bursa was performed, and fluid was sent for culture. Analgesia was provided.
- Consultations: Orthopedic surgery was consulted, and aspiration and intravenous antibiotics were recommended. The patient was admitted for continued management.
- Clinical course: The patient remained hemodynamically stable with persistent localized tenderness but no progression of swelling. Compartments remained soft without evidence of systemic toxicity or evolving septic arthritis.
- Disposition: Admitted to the Medicine service for intravenous antibiotics and continued management of suspected septic infrapatellar bursitis.

Discussion
Infrapatellar bursitis is an inflammatory condition involving the superficial or deep infrapatellar bursae located adjacent to the patellar tendon. These bursae function to reduce friction between the patellar tendon and surrounding soft tissues during knee movement. Inflammation may occur due to repetitive trauma, direct pressure, infection, or underlying inflammatory disease. Patients typically present with localized swelling, erythema, warmth, and tenderness over the anterior knee, which can mimic other soft tissue processes, including cellulitis, abscess, or septic arthritis.

Point-of-care ultrasound (POCUS) has become an increasingly valuable diagnostic tool in the emergency department for evaluating superficial musculoskeletal complaints. Ultrasound allows clinicians to rapidly distinguish between bursal fluid collections, joint effusions, abscesses, and cellulitis, which may have overlapping clinical presentations. In cases of infrapatellar bursitis, ultrasound commonly demonstrates a well-circumscribed fluid collection superficial to the patellar tendon, sometimes with surrounding soft-tissue edema. Ultrasound may also facilitate procedural guidance for diagnostic aspiration, particularly when septic bursitis is suspected.

In this case, bedside ultrasound demonstrated a localized fluid collection within the infrapatellar bursa, helping to narrow the differential diagnosis and guide further evaluation. Subsequent CT imaging confirmed an organized fluid collection without evidence of deeper infection, and ultrasound-guided aspiration was performed for diagnostic evaluation.

Bottom line: Point-of-care ultrasound is a rapid, effective method for evaluating anterior knee swelling in the emergency department. Early ultrasound evaluation can help identify bursal pathology, differentiate soft-tissue infections from other etiologies, and guide procedural management, thereby improving diagnostic accuracy and facilitating timely treatment.

References:
1. Jacobson JA. Fundamentals of Musculoskeletal Ultrasound. 3rd ed. Philadelphia: Elsevier; 2018.
2. Adhikari S, Blaivas M. Sonography first for subcutaneous abscess and cellulitis evaluation. Journal of Ultrasound in Medicine. 2012;31(9):1509–1512.
3. Long B, Koyfman A. Best Clinical Practice: Point-of-care ultrasound for musculoskeletal infections. Journal of Emergency Medicine. 2017;53(6):893–901.
4. Smith DL. Septic and nonseptic bursitis: evaluation and management. American Family Physician. 2003;67(5):949–956.
5. American College of Emergency Physicians (ACEP). Emergency Ultrasound Imaging Criteria Compendium. Annals of Emergency Medicine. 2011;58(4):387–403.

August 17, 2026August 17, 2026

Case 75: Detection of Choledocholithiasis Using Point-of-Care Ultrasound with Limited Visualization of the Common Bile Duct

Maya Ibelaidene, Rachna Subramony

A 45 year old male with a past medical history of gastric sleeve presented to the Emergency Department with two days of progressively worsening right upper quadrant (RUQ) abdominal pain. The pain was constant, dull in character, and radiated intermittently to the back. It was associated with nausea, vomiting, fever, chills, but no chest pain, or changes in bowel habits. He denied prior similar episodes, alcohol misuse, or known gallstone disease. There was no history of liver disease.

Vital Signs: BP 130/83 mmHg | HR 56 | T 98.7°F | RR 18 | SpO₂ 100% on room air

The patient appeared uncomfortable but was not in acute distress. Cardiopulmonary examination was unremarkable. Abdominal examination revealed focal tenderness in the RUQ with a positive Murphy’s sign. There was no rebound, guarding, or palpable mass. No scleral icterus was noted.

Laboratory studies demonstrated elevated liver enzymes with a cholestatic pattern: AST 186 U/L, ALT 501 U/L, alkaline phosphatase 512 U/L, and total bilirubin 6.2 mg/dL (direct predominance).

Given the patient’s RUQ pain and abnormal liver function tests, a point of care ultrasound (POCUS) of the RUQ was performed at the bedside to evaluate for biliary pathology. Examination was conducted using a low-frequency (2–5 MHz) curvilinear transducer. The gallbladder was assessed in longitudinal and transverse planes.

**Figure 1:** Markedly distended gallbladder with gallstones and posterior acoustic shadowing. Source: Radiopaedia

The gallbladder appeared significantly enlarged, consistent with biliary obstruction. Multiple echogenic foci with posterior acoustic shadowing were noted within the lumen.

Despite careful scanning, the common bile duct (CBD) was difficult to visualize clearly at the bedside. Attempts were made in multiple planes and patient positions; however, bowel gas and patient body habitus limited optimal delineation of the duct. No obvious intrahepatic biliary ductal dilation was confidently identified on POCUS.

Given laboratory evidence of cholestasis and a distended gallbladder concerning for distal obstruction, formal radiology performed ultrasound was obtained, demonstrating dilation of the CBD measuring 9 mm with an obstructing distal stone consistent with choledocholithiasis.

Subsequent magnetic resonance cholangiopancreatography (MRCP) confirmed the presence of a CBD stone. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with successful stone extraction and clinical improvement.

Discussion

Choledocholithiasis, defined as the presence of gallstones within the CBD, commonly presents with right upper quadrant pain, jaundice, and cholestatic liver enzyme abnormalities, and may progress to acute cholangitis or gallstone pancreatitis if untreated. POCUS is highly sensitive for detecting cholelithiasis and sonographic features of acute cholecystitis, but direct visualization of the CBD can be technically challenging in the emergency setting.

Bedside ultrasound reliably detects gallstones, gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy’s sign. In contrast, evaluation of the CBD requires deliberate technique and careful anatomic identification.

The duct is best located by first identifying the portal triad within the hepatoduodenal ligament. In a transverse view at the porta hepatis, the portal vein appears as the largest circular structure with echogenic walls. The CBD is typically positioned anterolateral to the portal vein, while the hepatic artery lies anteromedial forming the classic “Mickey Mouse sign,” which helps distinguish the CBD from adjacent vascular structures (Figure 2).

**Figure 2:** Example of “mickey mouse sign” on POCUS. Source: POCUS101

Color Doppler should be used to confirm that the suspected structure is nonvascular, as the CBD should not demonstrate internal flow (Figure 3). Optimal probe placement in the right upper quadrant along the midclavicular line with slight cephalad angulation, combined with rotation between longitudinal and transverse planes, improves visualization. Sliding medially toward the epigastrium and employing deep inspiration or left lateral decubitus positioning may further enhance acoustic windows. When visualized, the CBD should be measured inner wall to inner wall in the transverse plane, with diameters greater than 6 mm generally considered dilated in adults, though this threshold increases with age and prior cholecystectomy. Tracing the duct distally toward the pancreatic head may reveal obstruction, although distal visualization is frequently limited by bowel gas.

**Figure 3:** Identifying the CBD using color doppler. Source: Taming the SRU

Despite optimization strategies, POCUS has inherent limitations. Bowel gas, body habitus, and operator experience significantly affect image quality, and CBD stones are often not directly visualized. Instead, obstruction may be inferred through indirect findings such as intrahepatic biliary dilation or a markedly distended gallbladder. A case report by Herbst demonstrated POCUS identification of a dilated CBD in a patient with suspected choledocholithiasis, which subsequently normalized on repeat imaging after presumed spontaneous stone passage, underscoring both the dynamic nature of biliary obstruction and the value of serial assessment.¹ Systematic evaluations indicate that while ultrasound reliably identifies CBD dilation, its sensitivity for detecting CBD stones is significantly lower, which necessitates adjunctive imaging for definitive diagnosis.² More recent evidence supports integrating POCUS findings with clinical and laboratory data to improve diagnostic accuracy and expedite management in suspected choledocholithiasis.³

Given these limitations and evidence, confirmatory imaging such as comprehensive abdominal ultrasound, MRCP or ERCP is often required for definitive diagnosis and therapeutic planning.

In this case, the markedly enlarged gallbladder combined with cholestatic laboratory abnormalities heightened suspicion for distal biliary obstruction. Although the CBD was not clearly visualized on POCUS even with such a dilated gallbladder and later formal imaging revealing dilated CBD, the recognition of indirect sonographic findings appropriately prompted further imaging and facilitated timely intervention.

Conclusion

This case highlights both the utility and limitations of POCUS in the evaluation of suspected choledocholithiasis. While POCUS excels in the rapid identification of cholelithiasis and secondary signs of biliary obstruction, direct visualization of CBD stones remains challenging and operator dependent. Recognition of indirect findings such as gallbladder distention, intrahepatic ductal dilation, and supportive laboratory abnormalities plays a critical role in raising suspicion for distal obstruction.

Current literature supports the integration of serial POCUS examinations with clinical assessment and laboratory data to enhance diagnostic accuracy and guide timely management. However, due to its limited sensitivity for detecting CBD stones directly, confirmatory imaging with formal ultrasound, MRCP, or ERCP is often required.

Ultimately, this case underscores the importance of a multimodal diagnostic approach. When used thoughtfully, POCUS serves as a valuable first line tool that can expedite recognition of biliary obstruction, prompt appropriate additional imaging, and facilitate timely intervention, thereby improving patient outcomes in the emergency setting.

References

Herbst et al. Point-of-care ultrasound identification of transient common bile duct dilation due to choledocholithiasis. J Emerg Med. 2021. PMID: 33339646.
Meta-analysis assessing the diagnostic performance of ultrasound for CBD stones and dilation. Clin Imaging. 2014. PMID: 24126067.
Recent evaluation of POCUS utility in suspected choledocholithiasis and clinical decision support. Ultrasound Med Biol. 2022. PMID: 34995366.

August 14, 2026August 14, 2026

Case 74: Retinal detachment revealed through POCUS

Sabrina Straus, Rachna Subramony

A 68-year-old female with no past medical history on file presented to the emergency department for evaluation of a painless red left eye and visual disturbance. She reported noticing a horizontal line across her vision in the left eye for approximately one month. She described the visual phenomenon as a wave-like, ribbon-shaped distortion that appeared suddenly while she was at rest and had remained unchanged in severity since onset.

She denied eye pain, headache, diplopia, vertigo, focal weakness, sensory deficits, or other neurologic symptoms. She also denied trauma or prior ocular disease. The patient stated she did not feel any sensation at the time of onset but visually perceived the abnormality immediately.

Physical Exam:
The patient was alert, oriented, and in no acute distress. Head was normocephalic and atraumatic. Mucous membranes were moist. Extraocular movements were intact. Pupils were dilated secondary to ophthalmic drops administered prior to arrival by ophthalmology. Cardiopulmonary, abdominal, musculoskeletal, and neurologic exams were unremarkable with no focal deficits identified.

A bedside ocular ultrasound was performed.

**Figure 1.** Ocular ultrasound demonstrating a hyperechoic, linear, undulating membrane within the posterior chamber consistent with retinal detachment, anchored posteriorly.

**Figure 2.** Ocular ultrasound showing vitreous hemorrhage, characterized by heterogeneous, mobile hyperechoic debris within the posterior chamber that shifts with kinetic examination.

Ophthalmology was consulted and confirmed a macula-on retinal detachment secondary to a horseshoe tear of the left eye. Given the preserved macular involvement, the patient was scheduled for urgent surgical repair.

Discussion

Retinal detachment is a vision-threatening condition that can present with subtle and painless visual disturbances, particularly in cases where the macula remains attached.^{1, 2} This patient’s month-long history of a stable, wave-like visual defect without pain or neurologic symptoms highlights the diagnostic challenge posed by posterior segment pathology when the anterior ocular examination is unrevealing.

Point-of-care ocular ultrasound (POCUS) is a valuable diagnostic tool in the emergency department for evaluating acute and subacute visual complaints. The American College of Emergency Physicians endorses POCUS for posterior segment assessment, particularly when fundoscopy is limited or delayed.³^,⁴ Furthermore, meta-analyses and multicenter studies demonstrate high diagnostic accuracy of POCUS for retinal detachment, with reported sensitivities approximately 97% and specificities up to 96%.⁵^,⁶^,⁷^,⁸

An essential component of ocular POCUS interpretation is systematic visualization of key anatomic landmarks to accurately differentiate retinal detachment from other posterior segment pathology. Identification of the optic nerve is critical, as true retinal detachments remain tethered to the optic disc, appearing as a hyperechoic, linear membrane anchored posteriorly. Failure to visualize attachment to the optic nerve favors alternative diagnoses such as vitreous detachment. Evaluation of the lens is also important, as lens dislocation or subluxation may mimic posterior pathology or coexist with traumatic etiologies. The lens should appear as a symmetric, biconvex, hyperechoic structure positioned centrally behind the iris; abnormal position or contour suggests lens pathology rather than retinal disease. Additionally, assessment of the vitreous chamber is important to vitreous hemorrhage (mobile, heterogeneous echogenic debris) from retinal detachment (limited mobility). Systematic interrogation of these landmarks improves diagnostic accuracy and reduces false-positive interpretation, particularly in patients with subtle or chronic visual symptoms.⁷^,⁹^, ¹⁰

On ultrasound, retinal detachment typically appears as a hyperechoic, linear membrane that is tethered to the optic disc and demonstrates limited mobility with eye movement. This feature helps distinguish it from vitreous detachment, which appears more mobile and is not anchored posteriorly, and vitreous hemorrhage, which manifests as amorphous echogenic material that swirls with kinetic examination.¹¹ In this case, the ultrasound findings were consistent with retinal detachment and prompted immediate ophthalmologic confirmation.

Conclusion

Retinal detachment represents an ophthalmologic emergency, as timely surgical intervention is critical to preserving central vision. Early identification in the emergency setting can significantly impact visual outcomes. This case demonstrates how POCUS can facilitate rapid diagnosis and expedite specialist involvement, even in patients with minimal symptoms and prolonged presentation. Additionally, this case underscores the importance of considering posterior segment pathology in patients with persistent visual disturbances. Ocular POCUS provides a non-invasive, rapid bedside assessment that is particularly useful when pupil dilation, patient discomfort, or limited resources impede traditional ophthalmoscopic evaluation.

While POCUS does not replace comprehensive ophthalmologic examination, it serves as a crucial adjunct in the emergency department, enabling early recognition of sight-threatening conditions and guiding appropriate disposition. This case highlights the utility of ocular ultrasound in detecting clinically significant pathology and reinforcing timely intervention.

References

1. Retinal detachment - Symptoms and causes. Mayo Clinic. Accessed January 26, 2026. https://www.mayoclinic.org/diseases-conditions/retinal-detachment/symptoms-causes/syc-20351344

2. Haimann MH, Burton TC, Brown CK. Epidemiology of retinal detachment. Arch Ophthalmol. 1982;100(2):289-292. doi:10.1001/archopht.1982.01030030291012

3. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med. 2023;82(3):e115-e155. doi:10.1016/j.annemergmed.2023.06.005

4. Rice JA, Brewer J, Speaks T, Choi C, Lahsaei P, Romito BT. The POCUS Consult: How Point of Care Ultrasound Helps Guide Medical Decision Making. Int J Gen Med. 2021;14:9789-9806. doi:10.2147/IJGM.S339476

5. Lahham S, Shniter I, Thompson M, et al. Point-of-Care Ultrasonography in the Diagnosis of Retinal Detachment, Vitreous Hemorrhage, and Vitreous Detachment in the Emergency Department. JAMA Netw Open. 2019;2(4):e192162. doi:10.1001/jamanetworkopen.2019.2162

6. Vrablik ME, Snead GR, Minnigan HJ, Kirschner JM, Emmett TW, Seupaul RA. The diagnostic accuracy of bedside ocular ultrasonography for the diagnosis of retinal detachment: a systematic review and meta-analysis. Ann Emerg Med. 2015;65(2):199-203.e1. doi:10.1016/j.annemergmed.2014.02.020

7. Lahham S, Ali Q, Palileo BM, Lee C, Fox JC. Role Of Point Of Care Ultrasound In The Diagnosis Of Retinal Detachment In The Emergency Department. Open Access Emerg Med OAEM. 2019;11:265-270. doi:10.2147/OAEM.S219333

8. Gottlieb M, Holladay D, Peksa GD. Point-of-Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta-Analysis. Acad Emerg Med Off J Soc Acad Emerg Med. 2019;26(8):931-939. doi:10.1111/acem.13682

9. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med Off J Soc Acad Emerg Med. 2002;9(8):791-799. doi:10.1111/j.1553-2712.2002.tb02166.x

10. De La Hoz Polo M, Torramilans Lluís A, Pozuelo Segura O, Anguera Bosque A, Esmerado Appiani C, Caminal Mitjana JM. Ocular ultrasonography focused on the posterior eye segment: what radiologists should know. Insights Imaging. 2016;7(3):351-364. doi:10.1007/s13244-016-0471-z

11. Tandon A, Khullar T, Bhatt S. Sonography in acute ocular pathology: a kaleidoscopic view. Emerg Radiol. 2019;26(2):241-248. doi:10.1007/s10140-018-1655-2

August 11, 2026August 11, 2026

Review of the Use and Diagnostic Accuracy of the RUSH Exam for Internal Medicine

Sargis Manukyan, Akash Desai

Point-of-care ultrasound (POCUS) is an important tool for today’s practitioners. Studies have supported the use of POCUS in many clinical decision-making scenarios compared solely to standard examinations and other imaging modalities¹. Its integration in the emergency medicine (EM) setting has been pivotal and is now gaining momentum for implementation in internal medicine (IM).¹

POCUS differs from formal radiological US assessments in that it is a fast, dynamic bedside tool that both performed and interpreted by the sonographer-physician.² A recent systematic review demonstrated that in the hospital setting, integration of POCUS in clinical decision making helped change the primary diagnosis in up to 18% of patients, added a relevant diagnosis in up to 24% of cases, and had an impact on the management plan in 37% to 52% of the participants.³ Its use in trauma settings has been shown to reduce mortality and time to operative intervention.⁴ A recent quality improvement study found its use in internal medicine wards led to reduced hospital length of stay, with direct cost savings of $751,537 in a timespan of 6 months.⁵ Multiple groups have recognized the utility of POCUS in IM and have advocated for its integration into IM residency training, as well as created a collaborative model of EM and IM fellow training in POCUS.^6-8

One promising POCUS application in IM is in assessing patients with undifferentiated hypotension or shock. The Rapid Ultrasound for Shock and Hypotension (RUSH) exam introduced a standardized assessment of patients presenting with hypotension or shock. It includes evaluations of the heart, inferior vena cava (IVC), Extended Focused Assessment by Sonography in Trauma (E-FAST) abdominal views, and aorta. This can be remembered with the HI-MAP mnemonic, which stands for Heart, IVC, Morrison’s (the FAST exam), Aorta and Pneumothorax, and helps providers not miss steps in the sequence.⁹

The purpose of the RUSH exam is to assess the likely etiology of shock through evaluation of the pump (heart), the tank (volume), and the pipes (systemic vascular resistance).¹⁰ The four broad categories of shock include hypovolemic, obstructive, cardiogenic, and distributive. Different combinations of findings allow the physician to match the patient in front of them to a shock phenotype. For example, the presence of a hypercontractile heart with small collapsing chambers, a flat IVC, and the presence of peritoneal/pleural fluid in the setting of trauma argues for hypovolemic shock and should prompt appropriate volume resuscitation and concomitant source control. On the other hand, a hypocontractile or dilated heart, distended IVC, and presence of B-lines/pulmonary edema argue for cardiogenic shock and likely diuresis and consideration of vasoactive medications. Findings of pericardial effusion with tamponade physiology, RV strain, or absent unilateral lung sliding, all support a diagnosis of obstructive shock. Finally, hyperdynamic (early sepsis) or hypodynamic (late sepsis) heart contractility, variable IVC, and the appropriate laboratory correlates and infectious source argue for distributive shock.¹⁰

Cardiac ultrasound, demonstrating presence of pericardial effusion in a patient status post TAVR.

A prospective study showed that the RUSH exam had a sensitivity of 88% and specificity of 98% for identifying the type of shock with almost-perfect agreement between RUSH-based shock classification and the final clinical diagnosis (kappa of 0.84).¹¹ Furthermore, a meta-analysis of five articles looking into the diagnostic accuracy of RUSH showed high sensitivity and specificity of 87% and 98%, respectively, for detecting etiologies of shock.¹²

In evaluating the heart (pump), the examiner assesses left ventricular ejection fraction (LVEF), the presence or absence of pericardial effusion (Figure 1), and size of the ventricles relative to each other. Cardiac standard views include the parasternal long and short axes, apical four chamber, and subcostal four chamber views, which allow for appropriate characterization of these assessments.¹³ In assessing LVEF, visual estimation using POCUS has been shown to have a high accuracy when compared to gold standard transthoracic echocardiogram (TTE).¹⁴ IM residents with limited ultrasound training were able to detect ejection fraction (EF) <40% with 94% sensitivity and 94% specificity, even while using a lower fidelity hand-held POCUS device.¹⁵ After a 27-hour training, significant (5-fold) increase in positive likelihood ratio and decrease in negative likelihood ratio was seen for POCUS detection of left ventricular systolic dysfunction, severe mitral regurgitation, and moderate or large pericardial effusion.¹⁶ Pericardial effusion has been detected with a sensitivity of 96%, specificity of 98%, and overall accuracy of 97.5% by ED physicians using POCUS.¹⁷ An observational study showed that emergency department physicians could detect RV dilation with a high inter-rater agreement of 89%, which has been shown to have 50% sensitivity and 98% specificity of detecting pulmonary embolism (PE).^18,19

To evaluate the tank, examiner assesses central venous pressure using the IVC as a proxy. The probe is typically placed in the subxiphoid region with dynamic assessment of the IVC with respiration. Additional assessment of the lungs, pleural cavity, and abdominal cavity should be performed to identify findings of pulmonary edema (B-lines), pleural effusion (figure 2), or free intraperitoneal fluid.¹⁰ In assessing for cardiogenic pulmonary edema, presence of bilateral B-lines on lung ultrasound has been shown to be a strong indicator of interstitial pulmonary edema.²⁰Furthermore, POCUS has demonstrated higher diagnostic accuracy of detecting pleural effusions compared to chest x-ray (sensitivity of 95% vs 68%, respectively and specificity of 97% vs 85%, respectively).²¹ This multi-pronged sonographic assessment can help determine if a patient is likely to be fluid-tolerant or fluid-intolerant, and has demonstrated better test characteristics than the use of physical exam alone in assessing volume status.^{22, 23}

Right upper quadrant view showing a pleural effusion in a patient with pulmonary malignancy.

The final portion of RUSH evaluates the pipes. During this portion, the examiner assesses the patient’s arteries and veins. On the arterial side, detecting the presence of vascular catastrophes such as abdominal aortic aneurysm (AAA) rupture and aortic dissection is crucial, as these can be rapidly fatal causes of hypotension and shock.¹⁰

To assess the abdominal aorta, examiner should scan along its course, especially infrarenally where most AAAs occur. AAA is diagnosed when the aortic diameter is greater than 3 cm, measured in short axis from outer wall to outer wall, including any thrombus within the vessel.¹⁰ A systematic review demonstrated a pooled sensitivity and specificity of 99% and 98%, respectively, for detecting AAA by ED POCUS. Given only 50% of patients with AAA present with the classic triad of hypotension, back pain, and pulsatile abdominal mass on history, the application of POCUS may help with early diagnosis and treatment of this life-threatening disease.²⁴

The aortic root on parasternal long-axis cardiac view should also be assessed for dilation, or presence of an intimal flap which would aortic dissection. The abdominal aorta can be scanned for extension of a dissection flap.¹⁰ POCUS has been supported as useful triage tool for identifying high-risk patients who need urgent confirmatory imaging or intervention in acute type A aortic dissection.²⁵

The venous side of the pipes assessment focuses on IVC which has already been discussed, and deep venous thrombosis (DVT) (Figure 3). Compression ultrasound of the lower extremity veins can be used to identify DVT, with non-compressibility of the vein suggesting thrombus.¹⁰ A multicenter prospective cohort study demonstrated that hospital medicine providers can perform compression-only POCUS for DVT on hospitalized patients with a sensitivity of 100% and specificity of 95.8%, positive predictive value of 61% and negative predictive value of 100%, but, more importantly, with a significantly shorter median time to completion when compared to radiology-performed ultrasound (5.8 vs 11.5 hours).²⁶ In the setting of shock, the presence of DVT can support the diagnosis of obstructive shock from pulmonary embolism, especially when combined with other RUSH findings.¹⁰

Limb ultrasound, showing presence of DVT in a patient presenting with shortness of breath and calf pain.

Although the RUSH protocol is helpful in assessment of shock and hypotension, notable limitations exist. First, POCUS is operator and training-dependent with associated risk for false positive and false negative interpretations. Additionally, studies have yet to show mortality benefit with the use of POCUS in shock.² A systematic review comparing positive likelihood ratios across shock subtypes showed that RUSH was most accurate for detecting obstructive shock, with wide confidence intervals for hypovolemic, distributive, and mixed-etiology shock.²⁷ In addition, much of the evidence supporting RUSH comes from emergency department studies, so its diagnostic performance may not fully generalize to all hospitalized internal medicine patients.

Overall, POCUS has become an increasingly important tool in internal medicine, especially for evaluating patients with hypotension or shock. The RUSH exam provides a structured approach to identifying etiology of shock by assessing the pump, tank, and pipes. By rapidly evaluating cardiac function, volume status, lung findings, arteries, and presence of DVTs, RUSH can help clinicians narrow the differential diagnosis and initiate timely management. As with any other diagnostic study, findings must always be interpreted in the context of the patient’s history, physical exam, labs, and additional imaging. With appropriate training, RUSH can serve as a valuable addition to the assessment of hospitalized patients in internal medicine.

References:

Leidi, A., Rouyer, F., Marti, C., Reny, J. L., & Grosgurin, O. (2020). Point of care ultrasonography from the emergency department to the internal medicine ward: current trends and perspectives. Internal and Emergency Medicine 2020 15:3, 15(3), 395–408. https://doi.org/10.1007/S11739-020-02284-5
Díaz-Gómez, J. L., Mayo, P. H., & Koenig, S. J. (2021). Point-of-Care Ultrasonography. New England Journal of Medicine, 385(17), 1593–1602. https://doi.org/10.1056/NEJMra1916062
Cid-Serra, X., Hoang, W., El-Ansary, D., Canty, D., Royse, A., & Royse, C. (2022). Clinical Impact of Point-of-Care Ultrasound in Internal Medicine Inpatients: A Systematic Review. Ultrasound in Medicine and Biology, 48(2), 170–179. https://doi.org/10.1016/j.ultrasmedbio.2021.09.013
Ferrada, P., Evans, D., Wolfe, L., Anand, R. J., Vanguri, P., Mayglothling, J., Whelan, J., Malhotra, A., Goldberg, S., Duane, T., Aboutanos, M., & Ivatury, R. R. (2014). Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. The Journal of Trauma and Acute Care Surgery, 76(1), 31–38. https://doi.org/10.1097/TA.0B013E3182A74AD9
Maganti, K., Chen, C., Jamthikar, A. D., Parikh, P., Yanamala, N., & Sengupta, P. P. (2025). Cardiopulmonary Point-of-Care Ultrasonography for Hospitalist Management of Undifferentiated Dyspnea. JAMA Network Open, 8(9), e2530677–e2530677. https://doi.org/10.1001/JAMANETWORKOPEN.2025.30677
Eromosele, O. B., Pipilas, A., Sherer, J. A., & Schwartz, M. C. (2024). Advocating for an Advanced Cardiac POCUS Curriculum Among Internal Medicine Residents. Journal of Medical Education and Curricular Development, 11, 23821205241296957. https://doi.org/10.1177/23821205241296957
Ramgobin, D., Gupta, V., Mittal, R., Su, L., Patel, M. A., Shaheen, N., Gupta, S., & Jain, R. (2022). POCUS in Internal Medicine Curriculum: Quest for t he Holy-Grail of Modern Medicine. Journal of Community Hospital Internal Medicine Perspectives, 12(5), 36–42. https://doi.org/10.55729/2000-9666.1112
Baston, C. M., Wallace, P., Chan, W., Dean, A. J., & Panebianco, N. (2019). Innovation Through Collaboration: Creation of a Combined Emergency and Internal Medicine Point-of-Care Ultrasound Fellowship. Journal of Ultrasound in Medicine, 38(8), 2209–2215. https://doi.org/10.1002/JUM.14908;WGROUP:STRING:PUBLICATION
Dawson, M., & Mallin, M. (n.d.). Introduction to Bedside Ultrasound.
Perera, P., Mailhot, T., Riley, D., & Mandavia, D. (2010). The RUSH Exam: Rapid Ultrasound in SHock in the Evaluation of the Critically lll. Emergency Medicine Clinics of North America, 28(1), 29–56. https://doi.org/10.1016/J.EMC.2009.09.010
Bagheri-Hariri, S., Yekesadat, M., Farahmand, S., Arbab, M., Sedaghat, M., Shahlafar, N., Takzare, A., Seyedhossieni-Davarani, S., & Nejati, A. (2015). The impact of using RUSH protocol for diagnosing the type of unknown shock in the emergency department. Emergency Radiology 2015 22:5, 22(5), 517–520. https://doi.org/10.1007/S10140-015-1311-Z
Keikha, M., Salehi-Marzijarani, M., Soldoozi Nejat, R., Sheikh Motahar Vahedi, H., & Mirrezaie, S. M. (2018). Diagnostic Accuracy of Rapid Ultrasound in Shock (RUSH) Exam; A Systematic Review and Meta-analysis. Bulletin of Emergency And Trauma, 6(Issue 4), 271–278. https://doi.org/10.29252/BEAT-060402
Rowe, M., & Ferrada, P. (2026). Ultrasound to guide critical decisions: What you need to know. Journal of Trauma and Acute Care Surgery, 100(5), 692–699. https://doi.org/10.1097/TA.0000000000004815
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Razi, R., Estrada, J. R., Doll, J., & Spencer, K. T. (2011). Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. Journal of the American Society of Echocardiography, 24(12), 1319–1324. https://doi.org/10.1016/j.echo.2011.07.013
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Dresden, S., Mitchell, P., Rahimi, L., Leo, M., Rubin-Smith, J., Bibi, S., White, L., Langlois, B., Sullivan, A., & Carmody, K. (2014). Right ventricular dilatation on bedside echocardiography performed by emergency Physicians aids in the diagnosis of pulmonary embolism. Annals of Emergency Medicine, 63(1), 16–24. https://doi.org/10.1016/j.annemergmed.2013.08.016
Agricola, E., Bove, T., Oppizzi, M., Marino, G., Zangrillo, A., Margonato, A., & Picano, E. (2005). “Ultrasound Comet-Tail Images”: A Marker Of Pulmonary Edema: A Comparative Study With Wedge Pressure And Extravascular Lung Water. Chest, 127(5), 1690–1695. https://doi.org/10.1378/CHEST.127.5.1690
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August 8, 2026August 7, 2026

Case 73: Point-of-Care Ultrasound Detection of Uroperitoneum After Orthotopic Neobladder Creation

Hannah Oelschlager MD, Aarish Shahab MD, Rachna Subramony MD, Bryan Merte MD

A 63-year-old man with bladder cancer and type 2 diabetes mellitus presented on postoperative day 8 after robotic-assisted laparoscopic radical cystoprostatectomy with orthotopic neobladder creation. He had been discharged three days earlier with a transurethral Foley catheter in the neobladder and externalized ureteral stents draining into an abdominal collection appliance. His postoperative course had otherwise been uncomplicated, with adequate urinary drainage before discharge.

During the two days preceding presentation, he developed progressively worsening diffuse abdominal pain and markedly decreased urine output from both the Foley catheter and the externalized ureteral stents. The stents drained only intermittently and produced substantially less urine than previously. The pain was sharp, constant, and more severe on the right. He also reported chills and an inability to tolerate oral intake but denied fever.

Vital signs: BP 131/81 | HR 79 | RR 14 | SpO2 97% on room air | T 36.9°C.

On physical exam the patient appeared uncomfortable. His abdomen was diffusely tender, more prominently on the right, without rebound or guarding. He reported bilateral flank pain but had no costovertebral-angle tenderness. The abdominal stent exit sites and surrounding skin showed no erythema, bleeding, or discharge. His mucous membranes were dry, and capillary refill was delayed.

Lab Test	Value
WBC	12.3 x 10⁹/L
Hemoglobin	13.1 g/dL
BUN	16 mg/dL
Creatinine	2.61 mg/dL
Sodium	136 mmol/L
Potassium	4.4 mmol/L
Urinalysis	3+ blood 3+ protein + leukocyte esterase 21–50 WBCs >50 RBCs.

A renal POCUS examination and FAST-style intraperitoneal free-fluid assessment were performed to evaluate the patient’s abdominal pain, decreased urinary output, and elevated serum creatinine.

Figure 1: Right upper-quadrant view demonstrating anechoic free fluid adjacent to the caudal tip of the liver

*Figure 2:* Left upper-quadrant view demonstrating free fluid between bowel loops.

*Figure 3:* Long-axis view of the left kidney without hydronephrosis.

Contrast-enhanced CT of the abdomen and pelvis demonstrated moderate intraperitoneal free fluid, a decompressed neobladder with the Foley catheter in place, and no hydronephrosis. The distal ends of the ureteral stents had retracted from the neobladder lumen and were positioned within the peritoneal cavity. Delayed excretory-phase imaging demonstrated contrast-opacified urine extravasating into the peritoneal cavity, confirming uroperitoneum.

*Figure 4:* Coronal delayed excretory-phase CT image demonstrating contrast-opacified urine extravasating into the peritoneal cavity.

Clinical Course:

Given concern for a potentially infected urinary leak, the patient received intravenous fluids, analgesia, and empiric broad-spectrum antibiotics. Urology attempted bedside retrieval of the retracted ureteral stents in the emergency department but was unsuccessful. The left ureteral stent was subsequently removed by interventional radiology, but the right stent could not be retrieved. Bilateral percutaneous nephrostomy tubes were therefore placed for urinary diversion. Urine cultures showed no growth, and antibiotics were discontinued. The patient’s serum creatinine returned to 0.73 mg/dL, and he was discharged on postoperative day 13 with the nephrostomy tubes in place.

Discussion:

Radical cystectomy may be required for the management of bladder cancer. Orthotopic neobladder reconstruction is one urinary-diversion option and may offer continence and body-image advantages in appropriately selected patients.¹However, the procedure is technically complex and is associated with both early and late complications. Early complications, occurring within the first three months postoperatively, are often related to the intestinal and urinary tract and include urine leakage, bowel obstruction, and fluid collections.²Late complications include hydronephrosis, urinary tract infection, urinary calculi, bowel obstruction, vesicoureteral reflux, and neobladder rupture.

A bedside renal POCUS examination and modified FAST examination were performed during the initial evaluation of the patient’s abdominal pain, elevated serum creatinine, and decreased urine output. The FAST exam is most widely used in the trauma setting to detect free abdominal fluid with a pooled sensitivity and specificity of 74% and 98%, respectively.³However, a recent study utilizing a modified FAST exam to evaluate for intra-abdominal bleeding in postoperative cesarean section patients suggests it may be useful in selected postoperative patients. In a cohort of 61 patients, the modified FAST exam demonstrated a sensitivity of 80% and specificity of 100% for detecting intra-abdominal fluid.⁴Notably, all 10 false-negative examinations corresponded to “scant” or “trace” free fluid on formal imaging, and none of these patients required relaparotomy.

In the present case, POCUS demonstrated free intraperitoneal fluid in both upper quadrants without hydronephrosis. Ultrasound cannot reliably determine the composition of intraperitoneal fluid; therefore, the differential diagnosis included urine, blood, simple ascites, and an infected or sterile postoperative collection. The patient’s hemodynamic stability and hemoglobin concentration made major ongoing hemorrhage less likely. In the setting of recent urinary reconstruction, markedly decreased urinary drainage, and diffuse intraperitoneal free fluid, a postoperative urinary leak became a leading consideration.

Contrast-enhanced CT with delayed excretory-phase imaging confirmed urinary contrast extravasation into the peritoneal cavity. Delayed-phase CT is particularly useful for identifying urinary leakage and distinguishing urine from other postoperative fluid collections.⁵ In this patient, the distal ends of the ureteral stents had retracted from the neobladder lumen into the peritoneal cavity. This malposition likely allowed urine to drain into the peritoneal cavity rather than into the neobladder, producing uroperitoneum, also termed urinary ascites.

The patient’s serum creatinine increased from a baseline of 0.68 mg/dL to 2.61 mg/dL over three days. Renal POCUS demonstrated no hydronephrosis, making substantial upper urinary tract obstruction less likely. A component of true acute kidney injury remained possible given his poor oral intake and clinical evidence of volume depletion. However, in the presence of uroperitoneum, reverse peritoneal dialysis likely contributed substantially to the creatinine elevation. Urinary creatinine and other solutes can diffuse across the semipermeable peritoneal membrane into the systemic circulation, producing laboratory findings that mimic acute kidney injury despite relatively preserved glomerular filtration. This phenomenon is termed pseudo-azotemia or pseudo–acute kidney injury.⁶Hyperkalemia, hyponatremia, and metabolic acidosis have also been described. The return of the patient’s creatinine to 0.73 mg/dL after urinary diversion supported a substantial component of pseudo-azotemia.

Empiric antibiotics were administered because of concern for a potentially infected postoperative urinary leak. However, hematuria, pyuria, and positive leukocyte esterase should be interpreted cautiously in patients with ileal neobladders because abnormal urinalysis findings are common after urinary diversion. In a study of 185 patients with orthotopic ileal neobladders who underwent urinalysis 18 days after surgery, 80% had positive leukocytes, 83.8% had positive erythrocytes, and 41% had more than 20 leukocytes per high-power field.⁷The patient’s urine culture ultimately showed no growth, and antibiotics were discontinued.

In this patient, abdominal pain, decreased urinary output, elevated serum creatinine, and free intraperitoneal fluid on POCUS raised early concern for a postoperative urinary leak. POCUS could not determine the composition of the fluid but identified clinically significant intraperitoneal free fluid and facilitated early urologic consultation and delayed excretory-phase CT imaging. This case highlights uroperitoneum as an important cause of abdominal pain, oliguria, and apparent acute kidney injury after urinary reconstruction. The absence of hydronephrosis does not exclude urinary diversion failure, and an elevated serum creatinine may partly reflect reverse peritoneal dialysis rather than impaired renal filtration alone.

References:

1. Kubota H, Takahashi S, Monzawa S, et al. Pictorial review of orthotopic neobladder reconstruction: indication, normal postsurgical anatomy, and complications. Abdom Radiol. 2016;41(2):356-367. doi:10.1007/s00261-015-0576-8

2. Mirto BF, Barone B, Balsamo R, et al. Early and late post-procedural complications in different orthotopic neobladder surgical approaches: A systematic review. Surgical Oncology. 2024;55:102090. doi:10.1016/j.suronc.2024.102090

3. Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. Canadian Journal of Emergency Medicine. 2019;21(6):727-738. doi:10.1017/cem.2019.381

4. Treacy L, Newman R, Greene N, Gregory K. Postcesarean Delivery Use of a Modified FAST (Focused Assessment with Sonography for Trauma) Examination. Obstetrics & Gynecology. 2025;146(6):919-923. doi:10.1097/AOG.0000000000006108

5. Titton RL, Gervais DA, Hahn PF, Harisinghani MG, Arellano RS, Mueller PR. Urine leaks and urinomas: diagnosis and imaging-guided intervention. Radiographics. 2003;23(5):1133-1147. doi:10.1148/rg.235035029

Simler MAZ, Desouky E, Zakharious F, Mandal AKJ, Missouris CG. A Syndrome of Apparent Renal Failure. Ann Emerg Med. 2020;76(2):191-193. doi:10.1016/j.annemergmed.2020.02.018

7. Magistro G, Zimmermann L, Bischoff R, et al. The natural course of urinalysis after urinary diversion. World J Urol. 2021;39(5):1559-1567. doi:10.1007/s00345-020-03355-0

August 7, 2026August 7, 2026

Case 72: A Ureteral Jet in the Setting of Nonobstructing Nephrolithiasis

Liam DiZio, Elaine Yu

A 43-year-old female with a history of hepatic adenoma status post embolization and microwave ablation presented to the emergency department with one week of constant right flank and right lower chest wall pain. She denied fever, nausea, vomiting, dysuria, hematuria, chest pain, dyspnea, or recent trauma. An outpatient ultrasound performed two days prior demonstrated an 8 mm nonobstructing right renal calculus. Given her history, recurrent hepatobiliary pathology, nephrolithiasis, and musculoskeletal pain were at the top of her differential.

Vital Signs: BP 121/89 | HR 81 | RR 16 | Temp 98.0°F | SPO2 99% on FA

On examination, the patient was well appearing and in no acute distress. The abdomen was soft, non-distended, and non-tender without guarding or rebound. There was no costovertebral angle tenderness.

Creatinine was 0.74 mg/dL, lipase 32 U/L, and urinalysis was negative for blood, leukocyte esterase, nitrites, and WBCs.

Given the patient's persistent flank pain and concern for nephrolithiasis or urinary obstruction, a focused point-of-care renal and bladder ultrasound was performed.

**Figure 1.** Longitudinal grayscale image demonstrating a 6.5 mm nonobstructing right renal calculus.

Video 1. Color Doppler demonstrating a right ureteral jet entering the bladder.

Given reassuring ultrasound findings, a CT abdomen/pelvis with contrast was ordered to evaluate for hepatobiliary and renal pathologies. The CT confirmed a nonobstructive right nephrolithiasis. It also showed a stable hepatic adenoma with postprocedural changes and no evidence of active hemorrhage.

Hospital Course:

Given the reassuring laboratory evaluation and lack of obstructive findings/concerning hepatobiliary findings on imaging, the patient's symptoms were ultimately felt to be musculoskeletal rather than secondary to nephrolithiasis or a recurrent hepatobiliary pathology. She was discharged with conservative management and outpatient follow-up.

Discussion

Ureteral jets are intermittent bursts of urine entering the bladder from the ureterovesical junction during ureteral peristalsis and can be visualized on bladder ultrasound using color doppler. To view them, the bladder should be visualized in the transverse view with focus on the trigone [1]. Color doppler should then show intermittent jets of fluid entering the bladder within 5-10 minutes [1]. Absence of jets after five minutes of observation has an 87-95% sensitivity for complete ureteral obstruction [2]. However, because ureteral jets are intermittent and influenced by hydration status and bladder volume, they should always be interpreted in the context of the clinical presentation and other sonographic findings [3].

In this case, for example, despite the presence of a right renal calculus, this patient had no hydronephrosis and a robust ipsilateral ureteral jet on color doppler, supporting preserved ureteral patency. These findings were subsequently confirmed by CT, which demonstrated nonobstructive right nephrolithiasis.

Although ureteral jet assessment is not routinely incorporated into point-of-care ultrasound protocols for renal colic, it is a rapid, noninvasive addition to the exam that may improve diagnostic confidence when combined with grayscale findings [3]. This case highlights how evaluation of ureteral jets complemented the absence of hydronephrosis and supported the diagnosis of a nonobstructing renal calculus.

References:

Deschamps J, Dinh V, Ahn J, Genobaga S, Lang A, Lee V, Krause R, Tooma D, White S. Bladder ultrasound made easy: Step-by-step guide. POCUS 101. Published 2023. Accessed July 28, 2026. Available from: https://www.pocus101.com/bladder-ultrasound-made-easy-step-by-step-guide/
Gibbons RC, Chiem AT. Renal and genitourinary ultrasound evaluation in emergency and critical care: an overview. Diagnostics (Basel). 2024;14(12):1250.
Wong A, O'Connor M, et al. Bedside assessment of the kidneys and bladder using point-of-care ultrasound. POCUS J. 2023;8(1):22-32.