Author: UCSD Ultrasound

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Case 63:  Point-of-Care Ultrasound in Inferior Glenohumeral Dislocation (Luxatio Erecta) 

Makhlouf Bannoud, Colleen Campbell

 A 22-year-old male with no significant past medical history presented to the emergency department with right shoulder pain and visible deformity after a surfing injury. He reported that a wave forcefully pulled his surfboard while he was holding on, followed by an audible “pop.” He denied head trauma, distal numbness, weakness, or additional injuries. 

Vitals: BP 151/81 | HR 104 | RR 27 | Temp 97.8°F (36.6°C) | SpO₂ 93% 

On exam, the patient was in acute discomfort but alert and oriented. The right upper extremity was held in abduction with visible deformity and inferior displacement of the humeral head. Distal neurovascular exam demonstrated 2+ radial pulse, intact sensation in the axillary, median, radial, and ulnar distributions, and full motor strength in the hand. 

Point-of-care ultrasound (POCUS) of the right shoulder was performed prior to radiography to evaluate the glenohumeral joint. Ultrasound demonstrated inferior displacement of the humeral head relative to the glenoid fossa, consistent with inferior glenohumeral dislocation (Figure 1). No obvious joint effusion or cortical step-offsuggestive of displaced fracture was visualized. 

Figure 1: Inferior shoulder dislocation with humerus outside the glenoid fossa.

 Ultrasound guidance was then used to perform an intra-articular anesthetic injection for analgesia prior to reduction (Figure 2).

Figure 2: Ultrasound-guided joint injection.

Moderate procedural sedation with propofol was subsequently administered. Closed reduction was performed successfully. 

Post-reduction POCUS demonstrated restoration of normal alignment between the humeral head and glenoid (Figure 3). 

Figure 2: Post-reduction ultrasound.

Follow-up radiographs confirmed interval reduction and revealed a Hill-Sachs deformity without definitive osseous Bankart lesion. Repeat neurovascular examination remained intact. The patient was placed in a sling and discharged with close orthopedic follow-up. 

Discussion 

Inferior glenohumeral dislocation, or luxatio erecta, accounts for less than 1% of shoulder dislocations [1]. The classic mechanism involves hyperabduction, driving the humeral head inferior to the glenoid fossa. Patients typically present with the arm fixed in abduction and inability to adduct the limb. 

Although radiographs remain standard for definitive diagnosis, point-of-care ultrasound has emerged as a reliable adjunct for rapid diagnosis of shoulder dislocation. Multiple studies have demonstrated high sensitivity and specificity approaching 100% for identifying glenohumeral dislocation [2]. Ultrasound allows dynamic assessment without radiation and can expedite care in high-volume emergency settings. 

The posterior transverse view is most commonly used, with the probe placed over the scapular spine to visualize the glenoid and humeral head relationship. In normal alignment, the humeral head appears centered over the glenoid. In inferior dislocation, the humeral head is displaced caudally relative to the glenoid, as demonstrated in this case. 

POCUS also facilitates ultrasound-guided intra-articular anesthetic injection. Compared to landmark-based techniques, ultrasound guidance improves accuracy of joint entry and reduces complications [3]. Intra-articular lidocaine has been shown to be comparable to intravenous sedation in facilitating reduction, with shorter ED length of stay and fewer adverse events [4].

In this case, ultrasound-guided anesthetic injection was used as adjunctive analgesia prior to procedural sedation. Vascular injury, although rare, may involve the axillary artery. For this reason, careful pre- and post-reduction neurovascular examination is essential. 

Associated injuries are common and include Hill-Sachs deformity, greater tuberosity fracture, rotator cuffinjury, and labral tears. [5] Post-reduction imaging in this case demonstrated a Hill-Sachs lesion, which may predispose young active patients to recurrent instability depending on lesion size and engagement. 

This case highlights the expanding role of point-of-care ultrasound in musculoskeletal emergencies. POCUS enabled rapid confirmation of inferior glenohumeral dislocation, guided intra-articular anesthetic injection, and verified successful reduction prior to radiographic confirmation. When integrated thoughtfully into clinical workflow, ultrasound enhances procedural safety, diagnostic efficiency, and patient comfort in the management of shoulder dislocation. 

References: 

[1] StatPearls. (2023). Inferior shoulder dislocations. In StatPearls [Internet]. StatPearls Publishing. Retrieved October 2025, from https://www.ncbi.nlm.nih.gov/books/NBK448196/ 

[2] Gottlieb, M., Holladay, D., & Peksa, G. D. (2019). Point-of-care ultrasound for the diagnosis of shoulder dislocation: a systematic review and meta-analysis. The American Journal of Emergency Medicine, 37(4), 757-761. 

[3] Aly, A. R., Rajasekaran, S., & Ashworth, N. (2015). Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. British journal of sports medicine, 49(16), 1042-1049. 

[4] Sithamparapillai, A., Grewal, K., Thompson, C., Walsh, C., & McLeod, S. (2022). Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. Canadian Journal of Emergency Medicine, 24(8), 809-819. 

[5] Ostermann, R. C., Joestl, J., Hofbauer, M., Fialka, C., Schanda, J. E., Gruber, M., ... & Tiefenboeck, T. M. (2022). Associated pathologies following luxatio erecta humeri: a retrospective analysis of 38 cases. Journal of Clinical Medicine, 11(2), 453. 

[6] Flinders, A., & Seif, D. (2016). Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation). Journal of Medical Ultrasound, 24(2), 70-73 

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Case 62: Undifferentiated Hypotension in the setting of Atrial Fibrillation with Rapid Ventricular Response

Lucia Hong, Elaine Yu

A 70-year-old male with a history of cirrhosis, COPD, HTN, T2DM, and large abdominal wall hernia who presented after being found down in his home by a neighbor. Upon arrival, the patient was hypotensive with systolic blood pressures in the 70s and in atrial fibrillation with RVR with heart rates in the 170s. He received 500mL intravenous fluids prior to arrival and was transported on supplemental oxygen. The patient was altered and unable to provide history.

On physical examination, the patient appeared acutely ill and minimally responsive. Mucous membranes were dry. Cardiovascular examination demonstrated tachycardia with an irregular rhythm. Lung examination revealed bilateral breath sounds without focal wheezes or stridor. The abdomen was distended with generalized tenderness and a large non-reducible abdominal wall hernia. Extremities were warm and perfused without significant peripheral edema. Neurologic examination demonstrated altered mental status with intermittent command following and spontaneous movement of all extremities.

Synchronized cardioversion was performed following sedation with fentanyl and midazolam, which resulted in sinus tachycardia with improvement in heart rate and blood pressure.

Vital Signs: BP: 94/62 | HR: 102 | RR: 25 | Temp: 100 °F| SpO₂: 99% on 5L O2

Following cardioversion, RUSH was performed with findings of a small pericardial effusion, a plethoric inferior vena cava with minimal respiratory variation, and abnormal right ventricular wall motion with apparent right ventricular enlargement (Figure 1).

Additionally, intra-abdominal free fluid concerning for ascites was also seen (Figure 2). These findings prompted further evaluation of cardiogenic, obstructive, and distributive shock.

Figure 1. Apical 4-chamber view showing right ventricular enlargement with wall motion abnormality characterized as hypokinesia of the right ventricular free wall and contraction at the apex.1

Figure 2. Abdominal ultrasound showing large ascites in the left lower quadrant.2

Labs: WBC 13.3, Hgb 6.9, lactate 2.1, troponin 192 -> 189, D-dimer 26,069

Imaging

CTA PE: No definite pulmonary embolism. Mild volume overload, probably cardiogenic.

CT Abdomen/Pelvis with contrast: 4.7 cm left anterior bladder wall abscess. Large volume ascites.

Discussion

Undifferentiated hypotension in the emergency department presents a diagnostic challenge, particularly in patients with multiple comorbidities and competing etiologies of shock. Rapid Ultrasound in Shock and Hypotension (RUSH) examination has emerged as a critical bedside tool allowing evaluation of physiologic contributors to shock prior to definitive diagnostic testing. The RUSH protocol integrates focused cardiac, vascular, pulmonary, and abdominal ultrasound assessment to assess hypovolemic, distributive, cardiogenic, or obstructive etiologies.3 Incorporation of early bedside ultrasound has been shown to alter the presumed category of shock in up to 50% of patients presenting with nontraumatic hypotension.4 RUSH is associated with faster diagnostic clarification and earlier targeted therapy in critically ill emergency department patients.5 The utilization of POCUS has demonstrated high specificity for detecting right ventricular strain patterns associated with obstructive shock states.6 Furthermore, POCUS can improve evaluation of volume status and reduce potentially harmful fluid overload in critically ill patients.7

In this case, the patient presented with hypotension, altered mental status, and atrial fibrillation with RVR. Multiple or mixed shock etiologies were plausible, including septic shock from intra-abdominal infection, cardiogenic shock related to arrhythmia or myocardial injury, and obstructive shock with pulmonary embolism. Additionally, hypovolemia was also considered given an initial Hgb 6.9. Identification of right ventricular wall abnormalities increased clinical suspicion for obstructive pathology, and a subsequent D-dimer was noted to be significantly elevated. CTA PE was completed that ruled out pulmonary embolism and demonstrated volume overload from a likely cardiogenic cause. Further CT images identified a bladder abscess as a source of sepsis. Additionally, RUSH examination findings contributed to cautious fluid administration and prompted consideration of alternative shock mechanisms.

This case highlights how POCUS guides subsequent decision-making. As emphasized in current American College of Emergency Physicians guidelines, POCUS serves as an extension of the physical examination and plays an increasingly central role in the early evaluation of critically ill patients in the emergency department.8

References

1. Kansara T, Quesada F, Park H, Ghosh K, Saeed M. McConnell’s Sign Still Holds Its Value: A Lesson Learned From Two Cases. Cureus. 2019;11(11):e6240. doi:10.7759/cureus.6240

2. Zuidewind P. Cirrhosis and portal hypertension. Case study, Radiopaedia.org. Published June 21, 2020. https://radiopaedia.org/cases/cirrhosis-and-portal-hypertension-1

3. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid ultrasound in shock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010;28(1):29–56.

4. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004;32(8):1703–1708.

5. Atkinson PRT, Milne J, Diegelmann L, et al. Does point-of-care ultrasonography improve clinical outcomes in emergency department patients with undifferentiated hypotension? A systematic review and meta-analysis. Resuscitation. 2018;127:1–9.

6. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950–957.

7. Marik PE, Monnet X, Teboul JL. Hemodynamic Parameters to Guide Fluid Therapy. Ann Intensive Care. 2011;1:1.

8. American College of Emergency Physicians. Emergency Ultrasound Guidelines. Ann Emerg Med. 2017;69(5):e27–e54.

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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
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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.
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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.
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Case 58: Large Volume Paracentesis

Angela Wang, Benjamin Liotta

A 66-year old male with a longstanding history of alcoholic cirrhosis presents to the ED early in the morning requesting a paracentesis with 10 days of worsening abdominal distention in the setting of running out of his home furosemide several weeks prior. He denied fever, nausea, vomiting, or abdominal pain. 

 Vitals:  BP 151/99, HR 101, RR 20, T 97.6F, SpO2 100% 

On exam, his abdomen was grossly distended with a positive fluid wave and no peritoneal signs. His last paracentesis was done 2 weeks prior with 10L of fluid removed. IR was consulted but would not have availability until late afternoon, and after discussion with the patient, a paracentesis was performed in the ED. Ultrasound was used to visualize the fluid pocket and patient anatomy, to minimize risk to the patient. 

Figure 1: Perihepatic view. Cirrhotic, nodular liver and visible Morison’s pouch. The pocket of ascitic fluid visualized is approximately 5cm deep 

Figure 2: Transverse pelvic view, hyperechoic bowel loops can be visualized, as well as a 8-10 cm deep fluid pocket 

Figure 3: Limited left upper quadrant view. While the splenorenal space can be visualized, the perisplenic space, where ascites tends to preferentially accumulate (over the splenorenal space), cannot be seen in this image. 

Therapeutic and diagnostic paracentesis for ascites is commonly performed in the ED. The most common etiology for ascites is alcoholic cirrhosis, which makes up 80% of cases in western countries¹. Other causes include malignancy and heart failure¹. Prior to widespread use of ultrasound for routine bedside exams, paracenteses in the ED were commonly performed based on landmarks and could be associated with complications such as bleeding and damage to surrounding structures. A 2005 clinical trial showed the benefits of using ultrasound to guide needle placement during this procedure, with the authors finding a 95% success rate (defined by fluid aspiration) when ultrasound was used compared to a 68% success rate with the traditional technique⁵. A 2013 article also found that the use of ultrasound in paracenteses was associated with a 68% decrease in bleeding-related complications compared to the traditional technique⁴. 

A 2019 position statement by the Society of Hospital Medicine establishes recommendations for effective use of ultrasound to guide paracentesis. Ultrasound allows both identification of more superficial blood vessels to avoid with needle insertion as well as visualization of the peritoneal cavity to survey the anatomy and qualitatively and quantitatively describe any fluid within. Damage to abdominal wall vessels such as the inferior epigastric artery or vein can cause catastrophic bleeding, morbidity, and mortality². Identification of these vessels with color doppler prevents inadvertent vessel wall injury. As the ultrasound beam is only several millimeters wide, it is important to obtain views of multiple angles of the needle insertion site to ensure there are no vessels or underlying structures along the path of the needle².

Ascitic fluid is hypoechoic, while bowel is often hyperechoic due to bowel gas. Organs may be more heterogenous and of intermediate echogenicity³. Ultrasound can also be used to assess the fluid pocket itself. For example, a fluid depth of 2cm is recommended for procedural safety³. Ultrasound is more sensitive than x-ray to fluid as it is able to detect as little as 100 ml of fluid, compared to 500 ml for x-ray². Presence of heterogeneity within the fluid pocket can be suggestive of loculations, which may indicate a more likely malignant or inflammatory cause of ascites. 

The 66-year-old patient above had an uncomplicated paracentesis with needle placement in the left lower quadrant, and over 8 liters of fluid were removed from his abdomen. He tolerated it well and was discharged from the ED shortly after with follow-up with his PCP as well as a recommendation for regularly scheduled paracenteses with radiology. 

References:

1. AGA Clinical Practice Update on the Management of Ascites, Volume Overload, and Hyponatremia in Cirrhosis: Expert Review Orman, Eric S. et al. Gastroenterology, Volume 169, Issue 7, 1547 - 1557 

2. Cho J, Jensen TP, Reierson K, Mathews BK, Bhagra A, Franco-Sadud R, Grikis L, Mader M, Dancel R, Lucas BP; Society of Hospital Medicine Point-of-care Ultrasound Task Force; Soni NJ. Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Jan 2;14:E7-E15. doi: 10.12788/jhm.3095. PMID: 30604780; PMCID: PMC8021127. 

3. Kumar A, Dancel R, Galen BT et al. Ultrasound Guidance for Paracentesis. N Engl J Med. 2022;386(7):e15. doi:10.1056/NEJMvcm2119156 

4. Mercaldi CJ, Lanes SF, Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. (2013). Chest, 143(4), 1010–1015. https://doi.org/10.1378/chest.12-0447 

5. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study. Am J Emerg Med. 2005 May;23(3):363-7. doi: 10.1016/j.ajem.2004.11.001. PMID: 15915415. 

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Case 57: Positional Vertigo in the ED With Incidental Interatrial Shunt on Bubble Study

Carmon Controy, Akash Desai

44 y.o. male, brought by EMS from an outpatient procedure suite after sudden onset vertigo and gait instability following a right TMJ/ CNIII V3 injection. Patient experienced abrupt dizziness described as imbalance with ataxic gait, nausea, and one episode of emesis. The symptoms worsen with head movement/position change and improve at rest. No focal weakness, speech change, or headache reported. 

Pertinent PMHx: HIV on ART; cognitive impairment on donepezil/memantine; lumbar stenosis s/p L5–S1 decompression. Prior episodes concerning for TIAs/CVAs. 

Pertinent FHx: Patient states his father had a “hereditary hole in his heart” which was an incidental finding in his adult life, corrected with surgery.  

Vitals on Arrival: BP 146/88, HR 91, RR 16, SpO₂ 98% RA, afebrile 

Physical Examination:

  • General: No distress. 
  • Neuro: Alert/oriented; cranial nerves grossly intact; strength/sensation intact; left-beating nystagmus noted initially; abnormal ataxic gait on arrival. 
  • Cardiopulmonary/Abdomen: Unremarkable. 

ED Imaging and Tests:

  • CT/CTA Head & Neck (stroke protocol): No hemorrhage, large territorial infarct, LVO, or significant stenosis. 
  • MRI Brain (DWI): “Questionable subtle punctate” diffusion restriction in the left thalamocapsular region—artifact favored; tiny acute ischemic focus possible. No hemorrhage or mass effect. 
  • Neurology Consult: Vertigo most consistent with peripheral cause (positional trigger, brief episodes, improvement). HINTS/Dix-Hallpike negative when re-examined after symptom improvement. 
  • Labs: CBC/BMP/coags unremarkable. 
  • Cardiac Ultrasound: Transthoracic Echo with Agitated Saline (Bubble Study)
    • Normal LV size and EF ~54%; mild concentric LVH; normal RV size/function; no significant valvular disease. 
    • Bubble study positive: At rest, microbubbles appeared after 6–7 cardiac cycles; with Valsalva, a large, uncountable shower of bubbles traversed to the left heart—consistent with an interatrial shunt (e.g., PFO/ASD).

ED Course

Symptomatic therapy was provided (e.g., meclizine). Neurological symptoms improved during observation. Neurology judged low suspicion for central vertigo; recommended Epley if recurrent and discharge if symptoms resolved. Comprehensive stroke labs and imaging obtained. TTE with bubble study was positive for interatrial shunt as above, prompting recommendation for outpatient follow-up (stroke clinic/cardiology) to risk-stratify and discuss closure versus medical management in the context of prior suspected cerebrovascular events. 

Clinical course and neurology consultant assessment favored positional peripheral vertigo (likely posterior canal BPPV precipitated by head positioning during the OP nerve block procedure) over central causes; neuroimaging was equivocal for a tiny thalamocapsular DWI focus. However, the positive bubble study establishes an interatrial right-to-left shunt, providing a plausible pathway for paradoxical embolism. In a patient with a reported history of likely TIAs/CVAs (including possible TIA at the time of current evaluation), this finding heightens stroke risk considerations and may influence long-term secondary prevention (antithrombotic strategy) and candidacy for shunt closure after more thorough outpatient stroke-neurology/cardiology evaluation. 

Discussion 

This presentation is most consistent with peripheral, positional vertigo; the positive agitated-saline study is therefore best viewed as incidental to today’s symptoms.¹,² That said, a PFO is common (~20–25% of adults) and provides a plausible conduit for paradoxical embolism (especially when shunting becomes prominent with Valsalva), so its relevance is probabilistic and depends on clinical context rather than timing alone.³,² Frameworks like the Risk of Paraxodical Embolism (RoPE) score weigh age, event phenotype, and vascular risk factors to estimate whether a PFO is likely pathogenic versus incidental.⁴,⁵ Larger shunt burden and high-risk anatomy (e.g., atrial septal aneurysm) increase suspicion, while alternative mechanisms (occult AF, atherosclerosis, dissection, thrombophilia) must be assessed in parallel.⁶,⁵ 

For secondary cerebrovascular prevention, guideline-concordant work-up (e.g., rhythm monitoring for AF; targeted DVT evaluation; selective hypercoagulability testing) should inform therapy.⁷,⁶ In carefully selected patients 18–60 with a recent non-lacunar ischemic stroke of undetermined cause and a high-risk PFO, randomized trials (RESPECT long-term, CLOSE, REDUCE) show reduced recurrent stroke with percutaneous closure plus antiplatelet therapy compared with antiplatelet therapy alone, albeit with a small increase in atrial arrhythmias;⁸,⁹,¹⁰,¹¹ outside these criteria, optimized medical therapy is appropriate and decisions should be shared between stroke neurology and cardiology.⁶ Bottom line: (1) the PFO is likely incidental to this vertigo episode; (2) given prior TIAs/CVAs without a clear alternative mechanism, the PFO may have contributed to earlier events; and (3) the finding warrants formal risk stratification and guideline-based discussion of closure vs. medical therapy.⁴,⁵,⁶ 

References

  1. Collins S, Guntheroth WG, Raghu G, et al. Agitated saline contrast echocardiography: Contraindications, complications, and safety. J Am Soc Echocardiogr. 2022;35(1):13-21. doi:10.1016/j.echo.2021.10.016 
  1. Abdelmoneim SS, Mulvagh SL, Porter TR, et al. The clinical applications of ultrasonic enhancing agents in echocardiography: 2018 American Society of Echocardiography guidelines update. J Am Soc Echocardiogr. 2018;31(3):241-274. doi:10.1016/j.echo.2017.11.013 
  1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984;59(1):17-20. doi:10.1016/S0025-6196(12)60336-X 
  1. Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Ann Intern Med. 2013;158(5):285-292. doi:10.7326/0003-4819-158-5-201303050-00004 
  1. Kent DM, Dahabreh IJ, Ruthazer R, et al. Device closure of patent foramen ovale in patients with cryptogenic stroke: RoPE-estimated attributable fraction and treatment effect. Stroke. 2020;51(7):2143-2150. doi:10.1161/STROKEAHA.119.028966 
  1. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2021;52(7):e364-e467. doi:10.1161/STR.0000000000000375 
  1. Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(7):2160-2236. doi:10.1161/STR.0000000000000024 
  1. Saver JL, Mattle HP, Thaler DE. Patent foramen ovale closure versus medical therapy for cryptogenic ischemic stroke: a topical review. Stroke. 2018;49(6):1541-1548. doi:10.1161/STROKEAHA.117.018153 
  1. Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377(11):1022-1032. doi:10.1056/NEJMoa1610057 
  1. Mas J-L, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelet therapy after stroke (CLOSE). N Engl J Med. 2017;377(11):1011-1021. doi:10.1056/NEJMoa1705915 
  1. Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke (REDUCE). N Engl J Med. 2017;377(11):1033-1042. doi:10.1056/NEJMoa1707404 
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Case 56: Udderly Blinded: A Case of Chronic Ocular Trauma Unmasked by POCUS

Martin Day, Elaine Yu

A 69-year-old male with no significant past medical history presented to the emergency department after striking his right eye with the handle of a spray hose at work. He reported burning pain but denied bleeding, tearing, or other injuries. Eye movement did not exacerbate the pain. Notably, he had been chronically blind in the right eye since childhood after sustaining blunt ocular trauma from being kicked by a cow around age 12. He described no perception of light in that eye since then.

Vitals: BP 138/83 | Pulse 85 | Temp 98.4F (36.9C) | Resp 17 | SpO2 98%

Physical Exam:

On physical examination, the patient was alert and cooperative, not in acute distress. The right eye did not demonstrate periorbital ecchymosis or signs of obvious trauma. There was negative fluorescein uptake, extraocular movements intact, and pupil fixed. He had no light perception. His left eye was normal on examination.

A bedside ocular ultrasound was performed:

Figure 1. Bi-convex lens with hyperechoic but irregular borders.

Figure 2. Ocular ultrasound depicting hyperechoic debris within the posterior chamber and vitreous hemorrhage, represented as materials of varying echogenicity within the vitreous body.

ED Course

Pain was treated conservatively with topical anesthetics and fluorescein for exam. Patient did not require any acute intervention. He was reassured, educated on return precautions, and discharged in stable condition.

Discussion

Blunt ocular trauma can cause profound and often irreversible injury. In this patient, a cow kick to the eye at age 12 resulted in permanent blindness. Decades later, a new minor injury prompted re-evaluation, but his underlying chronic pathology was the dominant finding.

Despite an apparently benign surface exam—negative fluorescein, intact EOMI, no external trauma—ultrasound revealed chronic posterior segment pathology: vitreous detachment, hemorrhage, and irregular lens, consistent with his long-standing blindness. Notably, POCUS excluded emergent findings such as global rupture or retinal detachment.

The American College of Emergency Physicians recommends POCUS for assessing the posterior segment of the eye. Multicenter trials and meta-analyses convey high sensitivity and specificity for retinal detachment (96.9% sensitivity, 88.1% specificity), moderate diagnostic accuracy for vitreous hemorrhage (81.6% sensitivity, 82.3% specificity), and lower sensitivity (42.5%) but high specificity (96.0%) for vitreous detachment [1,2,3,5]. Additionally, POCUS was 100% sensitive and 97% specific for lens dislocation, and 100% sensitive and 99% specific for intraocular foreign body according to another meta-analysis [1,5].

Vitreous hemorrhage appears on ocular ultrasound as a fluid collection of variable echogenicity within the posterior chamber of the globe. The hemorrhagic material typically is mobile, shifting as the patient moves their eye while the probe remains still [2]. In chronic cases, fibrotic changes may cause the echogenic fluid collection to appear denser and more organized [1,2]. Vitreous detachment appears as a mobile, hyperechoic membrane in the posterior chamber, like vitreous hemorrhage, during kinetic examination [3]. Retinal detachment can be differentiated from vitreous detachment because it appears more echoic and anchored to the optic disc, which was not appreciated in this case [2,3]. The lens on ocular ultrasound may appear irregular in its position or contour [3]. This patient’s lens appeared typically centered behind the iris without evidence of dislocation. However, the margins were poorly defined, with irregular, asymmetric borders, suggestive of a lens irregularity [3,6].

In emergency medicine, ocular ultrasound offers a quick and effective means of evaluating both acute injuries and chronic sequelae. This case highlights the value of ultrasound in diagnosing both acute and chronic ocular pathology. It allows rapid, non-invasive assessment of posterior structures even when vision is absent or the anterior exam appears normal. A visit to the ED for a minor workplace incident uncovered sequela of a childhood injury. Additionally, clinical judgment helped guide diagnosis. With no suspicion of intraocular foreign body or orbital fracture, CT was deemed unnecessary. Ultrasound was sufficient to distinguish chronic from acute findings.  POCUS may be especially useful for assessing unreliable historians. POCUS does not replace the comprehensive ophthalmologic evaluation [4]. Nonetheless, it serves as a crucial tool for rapid bedside assessment for urgent intervention [4].

References

  1. American College of Emergency Physicians. Ultrasound Guidelines: Emergency, Point-of-Care, and Clinical Ultrasound Guidelines in Medicine. Irving, TX: American College of Emergency Physicians; 2023.
  2. 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
  3. Pyle M, Gallerani C, Weston C, Frasure SE, Pourmand A. Point of care ultrasound and ocular injuries: a case of lens dislocation and a comprehensive review of the literature. J Clin Ultrasound. 2021;49(3):282-285. doi:10.1002/jcu.22904
  4. Blaivas M, Theodoro D, Sierzenski PR. A study of bedside ocular ultrasonography in the emergency department. Acad Emerg Med. 2002;9(8):791-799. doi:10.1111/j.1553-2712.2002.tb02166.x
  5. Propst SL, Kirschner JM, Strachan CC, et al. Ocular point-of-care ultrasonography to diagnose posterior chamber abnormalities: a systematic review and meta-analysis. JAMA Netw Open. 2020;3(2):e1921460. doi:10.1001/jamanetworkopen.2019.21460
  6. Özdal M, Mansour M, Deschênes J. Ultrasound biomicroscopic evaluation of the traumatized eyes. Eye (Lond). 2003;17(4):467-472. doi:10.1038/sj.eye.6700382
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Case 55: Diagnosing Posterior Ocular Chamber Abnormalities with Point-of-Care Ultrasound

Kevin Vo, MD; Rachna Subramony, MD

Case Presentation:
A 31-year-old male with no significant past medical history presented to the Emergency Department with bilateral blurry vision, left greater than right. He had been evaluated earlier that day by an optometrist and referred for concern of retinal detachment. The patient reported flashes and floaters of uncertain duration but denied eye pain, discharge, foreign body sensation, headache, or trauma.

Vital Signs: BP 132/77 mmHg | HR 60 bpm | Temp 97.3°F | RR 16 | SpO₂ 99%

Physical Examination:
The patient was in no acute distress. Ocular exam revealed mild conjunctival injection bilaterally. Intraocular pressures were 17 mmHg OS and 13 mmHg OD. Fluorescein exam showed no corneal uptake. Neurologic exam was normal; the patient was alert and oriented ×3 without focal deficits. The patient reported a superior visual field deficit in the left eye.

A bedside ultrasound was performed.

Figure 1 (video) : Echogenic detached membrane visualized in the posterior chamber of the left eye

Figure 2 (video): Detachment tethered to the optic nerve.

Discussion: 

Point-of-care ultrasound (POCUS) is a valuable adjunct for emergency physicians in evaluating posterior ocular abnormalities. While anterior and external ocular conditions can often be diagnosed through history and physical examination, posterior chamber visualization is frequently limited in the emergency department due to the lack of specialized ophthalmic equipment and suboptimal exam conditions.

POCUS offers a noninvasive, rapid, and radiation-free imaging modality that can enhance diagnostic accuracy in the acute care setting. Meta-analyses and prospective studies have demonstrated POCUS sensitivity of 94–97% and specificity of 88–96% for detecting retinal detachment1,2,3. Given this high sensitivity, POCUS can serve as an effective rule-out tool when used in conjunction with ophthalmologic evaluation.

Retinal detachment typically appears as an echogenic, undulating membrane tethered to the optic nerve, a finding considered diagnostic in multiple studies.1,5 In this case, the optic nerve was difficult to visualize in the same plane as the detached membrane, making it challenging to definitively distinguish retinal from posterior vitreous detachment (Figure 2). However, given the patient’s corresponding visual field deficits and characteristic sonographic findings, the likelihood of retinal detachment remained high.

The use of POCUS for diagnosing vitreous detachment differs from its performance for retinal detachment. In one prospective study, sensitivity and specificity were 42.5% and 96% respectively.3 Another meta-analysis showed POCUS’s sensitivity to be 67% and specificity to be 90%. For other posterior eye pathologies, such as lens dislocation, foreign body, and globe rupture, sensitivity and specificity were high.1 The application of POCUS in this case was more suited for determining the presence of a retinal detachment and guiding the subsequent steps in management and further ophthalmologic assessment. The presence of vitreous detachment is difficult to rule out with the use of ultrasound alone. 

Conclusion:
This case demonstrates POCUS’s utility as an adjunct to ophthalmologic examination in the evaluation of posterior ocular pathology. Retinal detachment, which typically requires more urgent intervention than posterior vitreous detachment, can be rapidly identified using POCUS in the emergency setting. In this case, ophthalmology was consulted, and the patient subsequently underwent a left eye vitrectomy with perfluoro-octane (PFO) tamponade for treatment of his retinal detachment.

References: 

1.Propst SL, Kirschner JM, Strachan CC, et al. Ocular Point-of-Care Ultrasonography to Diagnose Posterior Chamber Abnormalities. JAMA Network Open. 2020;3(2):e1921460. doi:https://doi.org/10.1001/jamanetworkopen.2019.21460 

2.Gottlieb M, Holladay D, Peksa GD. Point‐of‐Care Ocular Ultrasound for the Diagnosis of Retinal Detachment: A Systematic Review and Meta‐Analysis. Carpenter CR, ed. Academic Emergency Medicine. 2019;26(8):931-939. doi:https://doi.org/10.1111/acem.13682 

3.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 Network Open. 2019;2(4). doi:https://doi.org/10.1001/jamanetworkopen.2019.2162 

4.Ocular Ultrasound Made Easy: Step-By-Step Guide - POCUS 101. POCUS 101. Published 2018. Accessed August 4, 2025. https://www.pocus101.com/ocular-ultrasound-made-easy-step-by-step-guide/#Posterior_Vitreou s_Detachment_PVD 

5.Kim DJ, Francispragasam M, Docherty G, et al. Test Characteristics of Point‐of‐care Ultrasound for the Diagnosis of Retinal Detachment in the Emergency Department. Theodoro DL, ed. Academic Emergency Medicine. Published online December 17, 2018. doi:https://doi.org/10.1111/acem.13454

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Case 54: Point-of-Care Ultrasound in Polycystic Kidney Disease with Hepatic Involvement

EJ Curtis, Colleen Sweeney, Colleen Campbell

A 70-year-old man with a past medical history of hypertension, obstructive hypertrophic cardiomyopathy, atrial fibrillation status-post Watchman procedure, and end-stage renal disease secondary to polycystic kidney disease (status-post renal transplant in 2014, complicated by chronic kidney disease stage 5 of the transplanted kidney) was brought to the emergency department after being found on the floor by his daughter. On arrival, the patient had generalized weakness, lightheadedness, and epigastric pain.

Vital signs: BP: 77/60 mmHg | HR: 103 | RR: 20 | T 37.3C

On physical exam, the patient appeared chronically ill and had scattered ecchymoses on bilateral upper extremities which he attributed to the recent fall. He also had bilateral lower extremity pitting edema which he says is stable since stopping furosemide. His abdomen was tender to palpation in the epigastric region with no rebound or guarding.

A bedside ultrasound was performed to evaluate for the source of abdominal pain.

Figure 1. Hepatorenal Junction

Figure 2. Splenorenal Junction

Figure 3. Multi-cystic liver parenchyma

Discussion:

Blood cultures grew out pseudomonas aeriginosa.  Patients with PKD can get septic from infected cysts however the source of his infection was not clear.

Polycystic kidney disease (PKD) is the most common inherited cause of end stage renal disease (ESRD) with the most common form, Autosomal Dominant PKD (ADPKD) affecting around 500,000 people in the United States and between 1 in 400 to 1 in 1000 births1. ADPKD is a progressive, multisystem disease associated with extrarenal manifestations of disease most associated with cysts in other organs such as the liver, seminal vesicle, and pancreas though connective tissue disorders including mitral valve prolapse, intracranial aneurysms, and abdominal hernias are also commonly reported2. Transplant of kidney is usually more successful after nephrectomy of native kidneys, with 1 year survival >90% and median survival of 18.7 years.

Polycystic liver disease (PLD), the most common extrarenal manifestation of PKD, is characterized by the presence of cysts in greater than 50 percent of the liver3. Between 75 and 90 percent of patients with ADPKD have associate PLD4. Notably, there is an inherited form of PLD, which is distinct from PKD but it is less common than PKD and is rarely associated with concurrent renal cysts 5.

The presence of innumerable hepatic cysts, as demonstrated in this case, provides a valuable sonographic teaching example for learners. It is critical to recognize that while renal disease is the primary driver of morbidity and mortality in ADPKD, extrarenal manifestations such as polycystic liver disease, intracranial aneurysms, and cardiac valvular disease are important contributors to patient outcomes and should be monitored and included as part of the differential diagnoses when these patients present to the emergency department. 

References:

  1. Mahboob M, Rout P, Leslie SW, Bokhari SR. Autosomal Dominant Polycystic Kidney Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. Updated March 20, 2024. Available from: NCBI Bookshelf 
  2. Pirson Y. Extrarenal manifestations of autosomal dominant polycystic kidney disease. Adv Chronic Kidney Dis. 2010 Mar;17(2):173–80. doi:10.1053/j.ackd.2010.01.003 
  3. Henriques MSM, Villar EJM. Chapter 17: The Liver and Polycystic Kidney Disease. In: Li X, editor. Polycystic Kidney Disease [Internet]. Brisbane (AU): Codon Publications; Nov 2015. doi:10.15586/codon.pkd.2015.ch17 
  4. Harris PC, Torres VE. Polycystic kidney disease. Annu Rev Med. 2009;60:321–37. doi:10.1146/annurev.med.60.101707.125712 
  5. Cnossen WR, Drenth JPH. Polycystic liver disease: an overview of pathogenesis, clinical manifestations and management. Orphanet J Rare Dis. 2014 May 1;9:69. doi:10.1186/1750-1172-9-69 
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