Category: Clinical Cases

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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

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

Vitals:
BP 138/87 | Pulse 62 | Temp 98°F (36.7°C) | Resp 19 | SpO₂ 99% | BMI 28.61 kg/m²

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

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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 TestValue 
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.1 However, 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.2 Late 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.3 However, 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.4 Notably, 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.6 Hyperkalemia, 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.7 The 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 

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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:

  1. 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/
  2. Gibbons RC, Chiem AT. Renal and genitourinary ultrasound evaluation in emergency and critical care: an overview. Diagnostics (Basel). 2024;14(12):1250.
  3. 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.
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Case 71: Chronic Back Pain

Letitia Mueller, Bryan Merte, Anthony Medak

A 73-year-old female presented from family health center for "unbearable" chronic back pain. She has a complex surgical history, including a T11-sacral posterior spinal fusion and an L3 corpectomy performed at a local outside hospital. She is chronically wheelchair-bound. The patient reported the pain is "stable" but reached a breaking point. She described "notches" forming on her thoracic spine. She denied acute lower extremity numbness, weakness, saddle anesthesia, or bowel/bladder incontinence. She denied fevers or recent trauma.

PMH: COPD on home O2, Hepatitis C, Major depressive disorder, Polycythemia, Pulmonary embolism, Schizophrenia, Active smoker                

Vitals: BP: 139/81, Pulse: 61, Temp: 98 °F, Resp: 16, SpO2: 95% on RA

Physical Exam:
General: Alert and oriented x4; non-toxic appearing.
MSK: Midline surgical scars over thoracic and lumbar spine. No bony step-offs, no deformity, and notably, no midline tenderness or skin changes.
Neuro: 5/5 strength in all extremities; sensation intact; no focal deficits noted.

Pertinent Labs: WBC 7.4k, Hgb 9.6, ESR >130, CRP 7.15

A bedside ultrasound was performed.

Abscess with "swirl sign" on compression circled in green. Reverberation artifact from metal hardware can be seen just deep to the abscess.

Learning Questions:

Q1: In a post-surgical patient with a "benign" physical exam but elevated inflammatory markers with the above ultrasound findings, what could be considered on the differential diagnosis?

A1: DDx would include: Abscess, seroma, hematoma…. Can you think of more? In this patient, the POCUS "Swirl Sign" suggests a purulent/infectious process. This was later confirmed by blood cultures positive for MRSA.

Q2: What do the cardiac ultrasound findings tell you about the patient’s hemodynamic status?

A2: The presence of a dilated Right Ventricle and the "D-sign" (septal flattening) indicates Right Heart Strain due to severe RV pressure overload. The RV is struggling to pump against significantly elevated pulmonary vascular resistance. This signifies that the patient is at higher risk for cardiovascular collapse.

ED Course:
Despite the benign physical exam, the markedly elevated inflammatory markers (ESR >130) and POCUS findings prompted a workup for deep-space infection. MRI of the spine confirmed edema and enhancement surrounding a 6.7 x 5.0 x 3.2 cm fluid collection within the surgical bed, involving a right-sided fusion rod. Patient was transferred to an outside hospital for continuity of care with prior surgical team for fluid drainage and spine hardware removal/revision.

During hospital admission:
Blood cultures confirmed MRSA Bacteremia, likely due to spinal abscess and infected spinal hardware. Patient was started on IV vancomycin and was scheduled for abscess drainage and spinal hardware revision surgery.

Discussion:

This case illustrates the application of point-of-care ultrasound (POCUS) as a bridge between a benign physical exam and definitive surgical management. A key sonographic finding in this case is the “swirl sign,” characterized by the movement of echogenic debris within a fluid collection when pressure is applied with the transducer. The presence of this "swirl" is highly suggestive of a complex collection, such as an abscess, hematoma, or seroma, rather than a simple cyst. In the context of a patient with significantly elevated inflammatory markers (ESR >130), this dynamic debris often points toward the purulent material of an abscess. By identifying this sign at the bedside, clinicians can escalate care, contrary to the approach that a benign physical exam might otherwise suggest. Also, given the artifacts created by metal hardware on MRI and CT, POCUS provides a rapid, non-invasive, and real-time imaging modality that can potentially reduce the time to directed antibiotic therapy or surgical intervention.

Beyond the localized infection, this case highlights the utility of POCUS in pre-operative risk stratification. The patient’s cardiac POCUS revealed a dilated Right Ventricle and a flattened interventricular septum (the "D-sign"). This is a hallmark of RV pressure overload, often seen in acute-on-chronic respiratory failure. According to the American Society of Echocardiography, the "D-sign" indicates that RV pressures have equaled or exceeded left ventricular pressures.

Despite a benign physical exam, bedside ultrasound identified a deep fluid collection. Additionally, cardiac POCUS provided immediate hemodynamic data, identifying RV pressure overload via the "D-sign”, which can be used for perioperative risk stratification in a patient with significant pulmonary disease. Ultimately, the bedside findings were confirmed by MRI, demonstrating that POCUS is a reliable tool for that allows for  rapid diagnosis and enhanced patient safety in complex surgical cases.

References:

  1. Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685-788. doi:10.1016/j.echo.2010.05.010
  2. Spinnato P, Patel DB, Di Carlo M, Bartoloni A, Cevolani L, Matcuk GR, Crombé A. Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review. Microorganisms. 2022 Nov 25;10(12):2329. doi: 10.3390/microorganisms10122329. PMID: 36557582; PMCID: PMC9784663.
  3. Subramaniam S, Bober J, Chao J, Zehtabchi S. Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections. Acad Emerg Med. 2016;23(11):1298-1306. doi:10.1111/acem.13049
  4. Vieillard-Baron A, Millington SJ, Sanfilippo F, et al. A decade of progress in critical care echocardiography: a narrative review. Intensive Care Med. 2019;45(6):770-788. doi:10.1007/s00134-019-05604-2
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Case 70: A Silent and Rapid Expansion

Natalie Sarafian, Elaine Yu

A 62-year-old male with a history notable for HFrEF (on Lasix), HIV, cirrhosis with varices, ulcerative colitis, methamphetamine use, and Hodgkin’s lymphoma (in remission) presents to the emergency department with acute onset shortness of breath and chest pain. His exertional dyspnea and exertional chest pain are also accompanied with lower extremity edema and orthopnea. Cardiac history is significant for CHF diagnosed in 2020, with a hospitalization in September 2025 for ADHF, and multiple recurrent admissions after being unable to take GDMT medications. Currently, he is adherent but misses medications about once weekly.

Vitals: BP 114/85, HR 103, RR 23, SpO2 94%, BMI 28.98

Physical exam: 2+ pitting edema in lower extremities bilaterally with a venous stasis rash

Labs: Troponin 85. BNPP > 13,000. Cr 1.23. Bilirubin of 1.54.

EKG: normal sinus rhythm with LBBB

A bedside ultrasound was performed:

Figure 1: Parasternal long axis view with severely decreased ejection fraction with trace pericardial effusion.
Figure 2: Parsternal short axis view with global hypokinesia and trace pericardial effusion.

ED Course: Cardiology was paged for the LBBB with troponin leak and heart failure exacerbation, with plan to admit to their service. In the interim, students performed another bedside ultrasound a few hours later for education.

Figure 3: Repeat examination showing increasing size of pericardial effusion.

Discussion:

Pericardial effusion management is routinely taught in medical education and encountered clinically. Pericardial effusions are present in about 6.5% of the general adult population and in 13-20% of high-risk emergency department patients [1]. Given its potential of developing into tamponade and its association with multiple diseases, prompt diagnosis is of utmost importance for proper treatment and prognosis of patients. Cardiac tamponade is an emergent consequence of a rapidly growing pericardial effusion, but it is infrequently encountered, with an incidence of 2 per 1000 people [2]. It is important to note that not all large pericardial effusions will devolve into tamponade; rather, a rapid rate of fluid accumulation creates tamponade [3].

The likelihood of discovering a pericardial effusion changes with a patient’s risk factors and underlying pathology. This patient had multiple comorbidities that are associated with cardiac pathology, including but not limited to CHF, methamphetamine use, HIV, lymphoma, and ulcerative colitis. In a meta-analysis of patients with pulmonary arterial hypertension, myocardial infarction, malignancy, and chronic heart failure, the pooled pericardial effusion prevalence was 19.5% [1]. Although pleural effusions are more common than pericardial effusions in CHF [5], pericardial effusions still demonstrate increased risk for all-cause mortality in CHF patients [6]. Now with antiretroviral therapies, studies have demonstrated low rates of pericardial effusions in HIV-positive outpatients [4]. Finally, the pericardium is a common site for lymphomas to metastasize [7], thus malignant pericardial effusions should also be considered in cancer patients.

Although echocardiograms are the basis of diagnosing pericardial effusions, a patient’s history, examination, EKG, or chest x-ray may raise suspicion [3]. Additionally, bedside ultrasound can also serve as an efficient and noninvasive diagnostic tool. POCUS has been found to reduce time to pericardiocentesis and expedite echocardiograms if indicated [8]. In fact, POCUS can be performed to confirm a pericardial effusion with 96-100% sensitivity and specificity [9]. Furthermore, when pericardial effusions are diagnosed in the emergency department, patients experience shorter hospital stays and reduced mortality [10].

Source: POCUS.org

When using POCUS to evaluate for pericardial effusions, measuring the effusion can help approximate the volume. It is important to note that up to 50 mL of fluid is normal and physiologic [10]. If there is clinical concern for tamponade, POCUS should evaluate for right ventricular diastolic collapse, late right atrial diastolic collapse, heart swinging, plethoric IVC, and mitral and tricuspid valve respirophasic flow variation [10]. Once a pericardial effusion and/or cardiac tamponade has been identified and diagnosed, treatment, ranging from conservative management to pericardiocentesis, should be considered.

In this patient’s case, the pericardial effusion was deemed small-moderate by the cardiology service and will be followed up with a formal echocardiogram.

References:

  1. Argulian, E. & Vogel, B. (2024) Evaluation of pericardial effusion. BMJ Publishing Group.
  2. Brown, B., Nigussie, B., Offor, R., & Graham-Hill, S. (2024). Fatal cardiac tamponade: The lethal progression of acute-on-chronic pericardial effusion. Cureus, PMC11264569.
  3. Shanker, D. A., Gaur, A., & Warriner, D. (2025). Pericardial effusion: Overview of aetiology, pathophysiology, diagnosis, and management. Cureus. https://pubmed.ncbi.nlm.nih.gov/41084698/
  4. Lind, A., Reinsch, N., Neuhaus, K., Esser, S., Brockmeyer, N. H., Potthoff, A., Pankuweit, S., Erbel, R., Maisch, B., & Neumann, T. (2011). Pericardial effusion of HIV-infected patients: Results of a prospective multicenter cohort study in the era of antiretroviral therapy. European Journal of Medical Research, 16(11), 480–483. https://pmc.ncbi.nlm.nih.gov/articles/PMC3351804/
  5. Natanzon, A. & Kronzon, I. (2009). Pericardial and pleural effusions in congestive heart failure—Anatomical, pathophysiologic, and clinical considerations. The American Journal of the Medical Sciences, 338(1). https://pubmed.ncbi.nlm.nih.gov/19574887/
  6. Georg M. Fröhlich, Philipp Keller, Florian Schmid, Mathias Wolfrum, Martin Osranek, Christian Falk, Georg Noll, Frank Enseleit, Markus Reinthaler, Pascal Meier, Thomas F. Lüscher, Frank Ruschitzka, Felix C. Tanner, Haemodynamically irrelevant pericardial effusion is associated with increased mortality in patients with chronic heart failure, European Heart Journal, Volume 34, Issue 19, 14 May 2013, Pages 1414–1423, https://doi.org/10.1093/eurheartj/eht006
  7. Mudra, S. E., Rayes, D., Kumar, A. K., Li, J. Z., Njus, M., McGowan, K., Charalampous, C., Kalam, K. A., Syed, A., Majid, M., Schleicher, M., Agrawal, A., Yesilyaprak, A., & Klein, A. L. (2024). Malignant pericardial effusion: A systematic review. CJC Open, 6(8), 967–972. https://pmc.ncbi.nlm.nih.gov/articles/PMC11357784/
  8. Moura de Azevedo, S., Duarte, R., Krowicki, J., Vázquez, D., Pires Ferreira Arroja, S., & Mariz, J. (2024). Heart in focus: Advancing pericardial effusion diagnosis with point-of-care ultrasound. Cureus, 16(12), e76681. https://pmc.ncbi.nlm.nih.gov/articles/PMC11781757/
  9. Merth, T. & Sachdeva, S. (2022). Pericardial effusion and tamponade: Diagnosis and treatment summary. https://emergencycarebc.ca/clinical_resource/clinical-summary/pericardial-effusion-and-tamponade-diagnosisand-treatment-summary/
  10. Rao, V. (2025). POCUS evaluation of pericardial effusion and tamponade. https://www.pocus.org/pocusevaluation-of-pericardial-effusion-and-tamponade/
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Case 69: Expedited Workup for a Low-Risk Pulmonary Embolism

Julia Kelly, Cameron Smyres

A 62-year-old man who was recently diagnosed with colon cancer presents to the ED after being diagnosed with a pulmonary embolism on outside CT imaging. The patient had a CT scan of his chest for cancer staging and an incidental PE was found. He was told to seek care at the ED. The patient is asymptomatic, and specifically denies chest pain, dyspnea, acute leg swelling and otherwise feels at his baseline. He denies any recent travel and has no history of blood clots in the past.

Vitals: BP 106/70 | Pulse 55 | Temp 98 °F (36.7 °C) | Resp 19 | Wt 79.8 kg (176 lb) | SpO2 98%

Physical Exam: The patient is not in acute distress, lying in bed and breathing comfortably on room air. Lungs are clear to auscultation bilaterally. 1+ pitting edema noted in shins bilaterally. The remainder of the exam is normal.

Labs: CBC with stable chronic macrocytic anemia (Hgb 11.7). CBC, PT and PTT wnl.

Figure 1: Parasternal long (no RV dilation)
Video 1: Parasternal short (no D sign present, symmetric squeeze of LV)

ED Course: Limited bedside cardiac ultrasound showed grossly normal heart function, without pericardial effusion or right ventricular dysfunction. No evidence of right heart strain. PE team was consulted who did not recommend formal echocardiogram based on patient’s lack of symptoms, hemodynamic stability, and reassuring bedside ultrasound. Patient was started on Eliquis and referred to PE clinic for outpatient follow up.

Discussion:

Pulmonary embolism (PE) is a potentially life-threatening diagnosis that can present with a variety of symptoms, from asymptomatic to sudden hemodynamic collapse. Approximately half of PEs are diagnosed in the emergency care setting,4 making rapid identification and risk stratification especially important. Mortality can reach up to 25-50% in massive PE without prompt treatment. POCUS has been shown to be highly sensitive for large PEs and in those with abnormal vital signs.1

A rapid bedside tool, POCUS can play an important role in risk stratification of patients with PEs by evaluating for right heart strain, though data shows its utility in diagnosing PE itself might be more limited5. Pulmonary emboli block blood flow to the lungs, increasing afterload, leading to right ventricular dysfunction (RVD). RVD is an important prognostic factor and can change management. In this case, bedside echo demonstrated no evidence of right ventricular dysfunction, supporting outpatient management with apixaban and close follow-up; in contrast, evidence of right heart strain may have prompted consideration of more aggressive therapies or inpatient monitoring.

There are several sonographic findings that suggest right heart strain, including RV enlargement (RV:LV ratio), abnormal septal motion such as septal flattening (“D-sign”), and McConnell’s sign (hypokinesis of RV with apical sparing, resembling a flailing sail3). These features reflect acute pressure overload on the RV from a significant pulmonary arterial obstruction. McConnell’s sign is an indication of acute RV strain, rather than chronic changes. Acute RV strain can also be distinguished from chronic overload with the absence of RV hypertrophy.5 It is important to note that the sensitivity of POCUS for detecting right heart strain in PE is limited. For example, McConnell’s sign shows high specificity but low sensitivity for acute PE: one study finding a pool estimate of 22% sensitivity and 97% specificity.4 Additionally, absence of right heart strain on POCUS does not exclude PE, and CT PE remains the gold standard for definitive diagnosis.

In summary, while POCUS did not reveal right heart strain in this patient with confirmed PE, its use provided timely bedside evaluation of cardiac function that contributed to risk stratification and informed clinical management. This case highlights POCUS’s role as a valuable tool in the assessment of suspected PE.

References

  1. Alerhand S, Sundaram T, Gottlieb M. What are the echocardiographic findings of acute right ventricular strain that suggest pulmonary embolism? Anaesth Crit Care Pain Med. 2021 Apr;40(2):100852. doi: 10.1016/j.accpm.2021.100852. Epub 2021 Mar 26. PMID: 33781986.
  2. Daley JI, Dwyer KH, Grunwald Z, Shaw DL, Stone MB, Schick A, Vrablik M, Kennedy Hall M, Hall J, Liteplo AS, Haney RM, Hun N, Liu R, Moore CL. Increased Sensitivity of Focused Cardiac Ultrasound for Pulmonary Embolism in Emergency Department Patients With Abnormal Vital Signs. Acad Emerg Med. 2019 Nov;26(11):1211-1220. doi: 10.1111/acem.13774. Epub 2019 Sep 27. PMID: 31562679.
  3. Day J BA RDCS. Right Heart Evaluation | Point-of-Care Ultrasound Certification Academy [Internet]. Point-of-Care Ultrasound Certification Academy. 2023. Available from: https://www.pocus.org/right-heart-evaluation/
  4. Fields JM, Davis J, Girson L, Au A, Potts J, Morgan CJ, Vetter I, Riesenberg LA. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr. 2017 Jul;30(7):714-723.e4. doi: 10.1016/j.echo.2017.03.004. Epub 2017 May 9. PMID: 28495379.
  5. Rudski LG, Wyman WL, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardio. 2010;23(7):685-713.
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Case 68: Erector Spinae Plane Block for Rib Fracture Pain

Anthony Galvez, Tommy Ngo, Akash Desai

A 62yo male with a history of HIV and hypothyroidism presents to the ED with left-sided chest pain and shortness of breath after a near-syncopal episode followed by a fall 3 days prior. The patient was carrying groceries when he suddenly felt lightheaded and fell to the ground. He denies loss of consciousness or head trauma and reports having not eaten or drinking anything all day. Since the fall, he has had progressively worsening left-sided chest pain and spasming.

Vitals: BP 157/87, HR 70, RR 18, T 98.3F, SpO2 98%

Exam:

  • The patient appeared uncomfortable, splinting with respirations, and was wearing a self-applied weightlifting brace over the left chest wall.
  • Chest wall examination revealed focal tenderness to palpation over the left lateral and posterior ribs without overlying ecchymosis, crepitus, or step-off deformity. There was no flail segment appreciated. Auscultation revealed clear and equal breath sounds bilaterally.
  • Cardiac exam was regular without murmurs.
  • The abdomen was soft and non-tender.
  • Neurologic exam was grossly intact with no focal deficits.

ED Course:

  • Syncope workup showed no significant electrolyte derangements or anemia.
  • Chest x-ray was obtained to evaluate for trauma which showed acute displaced left posterior 4th-7th rib fractures. No pleural effusion or pneumothorax was seen.
  • After administration of ibuprofen, acetaminophen, and oxycodone, the patient’s pain was still reported as 8-9/10. The patient was offered and consented to an erector spinae plane block for multimodal pain control.
  • The block was performed at bedside using ultrasound guidance (Figures 1-2). Half an hour after the block was performed, the patient’s pain had reduced to 4/10. The patient reported increased range of motion and subsequently was able to walk himself to the bathroom.
  • The patient was subsequently cleared by trauma surgery for discharge home with multimodal pain control and follow up with PCP.
Figure 1: With transducer dot caudally, the needle is inserted and aimed at the transverse process. A faint echogenic line represents the needle terminating on the transverse process (TP).
Figure 2: With the needle pressed against the transverse process, the anesthetic is injected just below the erector spinae muscle. An arrow depicts the injectate, which should be seen spreading across the underside of the erector spinae (ES) muscle.

Discussion
Effective pain control in patients with rib fractures is critical to prevent complications such as atelectasis, pneumonia, and respiratory failure.1,2 Traditional management often relies on systemic opioids, which carry known risks including respiratory depression, cough suppression, and delirium.3 The erector spinae plane block (ESPB) is a regional anesthesia technique that provides effective analgesia for thoracic wall pain while reducing opioid requirements.4,5,6 In this case, ESPB resulted in a clinically meaningful reduction in pain and improved range of motion after failure of multimodal oral analgesia and facilitated safe discharge from the emergency department. The ESPB is well suited for the emergency room setting as it can easily be done at bedside using ultrasound guidance and is performed away from the pleura and other critical structures.5,6 Additionally, this technique is more technically straightforward in comparison to paravertebral or epidural blocks, which require greater technical expertise and carry higher risk.7,8 By targeting the fascial plane at the level of the transverse process, there is consistent blockade of the dorsal rami, with variable anterior spread to the ventral rami and intercostal nerves, allowing the ESPB to effectively provide broad unilateral analgesia across multiple rib levels4,5,9,10 (Figures 3-5).

Figure 3. Probe positions and corresponding ultrasound views at three lateral levels: spinous process (midline), transverse process (~3 cm lateral), and rib. The transverse process appears blunted and squared vs. the rounded rib shadow; pleura is visible deep to the rib but obscured behind the TP. (Source: Highland Ultrasound).
Figure 4. Posterior thoracic musculature with the right side partially reflected to expose the spine. The needle (center) is shown targeting the ESP at the level of the transverse process. Both superior and inferior approaches are demonstrated with the ultrasound transducer (blue) positioned in the parasagittal plane. Yellow nerves visible on the left demonstrate the multilevel coverage achieved by cephalocaudal LA spread. (Source: Regional Anesthesiology and Acute Pain Medicine).
Figure 5. Cross-section at T5 showing local anesthetic (dark blue) injected into the erector spinae plane (ESP), with anterior spread (light blue) toward the dorsal ramus (DR), ventral ramus (VR), and intercostal nerves (IC). Needle target is deep to the erector spinae (ES) and rhomboid (Rh), superficial to the transverse process (TP). (Source: Highland Ultrasound)

References:

  1. Hamilton DL, Manickam B. Erector spinae plane block for pain relief in rib fractures. Br J Anaesth. 2017;118(3):474-475. doi:10.1093/bja/aex013
  2. Luftig J, Mantuani D, Herring AA, Dixon B, Clattenburg E, Nagdev A. Successful emergency pain control for posterior rib fractures with ultrasound-guided erector spinae plane block. Am J Emerg Med. 2018;36(8):1391-1396. doi:10.1016/j.ajem.2017.12.060
  3. Peek J, Smeeing DPJ, Hietbrink F, Houwert RM, Marsman M, de Jong MB. Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis. Eur J Trauma Emerg Surg. 2019;45(4):597-622. doi:10.1007/s00068-019-01116-w
  4. Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The erector spinae plane block: a novel analgesic technique in thoracic neuropathic pain. Reg Anesth Pain Med. 2016;41(5):621-627. doi:10.1097/AAP.0000000000000451
  5. Kumar G, Kumar Bhoi S, Sinha TP, Paul S. Erector spinae plane block for multiple rib fracture done by an emergency physician: a case series. Australas J Ultrasound Med. 2021;24(3):167-172. doi:10.1002/ajum.12261
  6. Jiang M, Peri V, Ou Yang B, Chang J, Hacking D. Erector spinae plane block as an analgesic intervention in acute rib fractures: a scoping review. Local Reg Anesth. 2023;16:81-90. doi:10.2147/LRA.S414056
  7. Palachick BJ, Carver RA, Byars DV, Martyak MT, Collins JN. Erector spinae plane blocks for traumatic rib fractures performed by nonspecialized emergency physicians: a prospective, interventional study. Am Surg. 2022;88(9):2124-2126. doi:10.1177/00031348221078428
  8. Elawamy A, Morsy MR, Ahmed MAY. Comparison of thoracic erector spinae plane block with thoracic paravertebral block for pain management in patients with unilateral multiple fractured ribs. Pain Physician. 2022;25(6):483-490.
  9. Ivanusic J, Konishi Y, Barrington MJ. A cadaveric study investigating the mechanism of action of erector spinae blockade. Reg Anesth Pain Med. 2018;43(6):567-571. doi:10.1097/AAP.0000000000000789
  10. Chin KJ, El-Boghdadly K. Mechanisms of action of the erector spinae plane (ESP) block: a narrative review. Can J Anaesth. 2021;68(3):387-408. doi:10.1007/s12630-020-01875-2

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Case 67: D-sign in a Post-Cardiac Surgical Patient

Liz Temple, Colleen Campbell

A 51-year-old male patient with past medical history of mitral valve prolapse s/p complex mitral valve repair with left atrial appendage exclusion and repair of atrial septal defect complicated by perioperative pericarditis was directly admitted to the ICU following outpatient echocardiography findings of new right heart strain. Since his open heart surgery, he began to develop progressive dyspnea on exertion and orthopnea accompanied with dizziness and lightheadedness. His exertional capacity has decreased from 3 miles to 100 yards over one week. He otherwise denied fevers,

chills, abdominal pain, or dysuria. He completed an outpatient echo which showed evidence of new severe RV dysfunction which was new compared to his post-operative echo after his complex cardiac surgery which showed preserved RV function. CT PE was completed to rule out PE and did not show evidence of a clinically significant PE as the cause of his new onset RV dysfunction. Bedside cardiac ultrasound was also performed once the patient arrived to the floor.

Vitals: BP 128/75 | Pulse 86 | Temp 97.7 °F (36.5 °C) | Resp 17 | SpO2 98% | BMI 24.4 kg/m²

Physical Exam:

Gen: well appearing, NAD

HEENT: normocephalic, atraumatic, moist mucous membranes, sclera anicteric, EOMI

CV: WWP, RRR, radial pulses 2+, JVP ~9cm

Resp: no increased work of breathing, no accessory muscle use, speaks in full

sentences, breathing comfortably on RA, CTAB

Abd: soft, nontender, nondistended

Ext: no lower extremity edema

Neuro: moves all limbs spontaneously, no facial asymmetry, no dysarthria, EOMI

Labs: Troponin within normal limits

Figure 1. Cardiac POCUS with parasternal long axis showing dilated right ventricle (RV). No evidence of a significant pericardial effusion although there appears to be an echogenic focus on anterior RV free wall.
Figure 2: Parasternal short axis view from formal echocardiogram displaying the “D-sign” of right ventricular strain.
Figure 3: Apical 4-chamber view from formal echocardiogram demonstrating septal bowing into left ventricle most prominently during diastole.

Discussion

The “D-sign” on cardiac POCUS can help to identify right heart strain of varying etiologies, and is often considered a canonical sign for pulmonary embolism. This finding is most clearly visualized using a parasternal short axis view where the left ventricle appears as a D-shaped structure as a result of right ventricular overload which causes the interventricular septum to bow towards the left heart.1,2

While the D-sign has a high specificity (83%), it has a low sensitivity (53%) for pulmonary embolism. Moreover, there are a series of other underlying etiologies of right heart strain that may be associated with this ultrasound signature apart from pulmonary embolism.3

More specifically, right ventricular strain can be stratified by whether it is a result of pressure overload versus volume overload. In a patient with right ventricular pressure overload, elevated pressures on the right side are present both during systole and diastole, and therefore the left ventricular “D-shape” is present throughout the cardiac cycle. Pathologies that correlate with right ventricular pressure overload include pulmonary embolism, pulmonary hypertension, chronic right hear failure with hypertrophy, left-sided heart failure, and ARDS. Conversely, in patients with right ventricular volume overload, the sequelae of volume overload are most apparent during diastolic filling, so the D-sign is most obvious at end diastole while the left ventricle appears more normal and circular shaped during end-systole.4 Conditions that correlate with right ventricular volume overload may include severe tricuspid regurgitation, decompensated heart failure, and excessive volume resuscitation.1

A quantitative tool that is used to distinguish these forms of overload is the Eccentricity Index which utilizes the cross-sectional measurement of the left ventricular cavity in the parasternal short axis view. The index is a proportion between the measurement of length parallel to the septum (D2) and perpendicular to the septum (D1): EI = D2/D1. An EI>1 is suggestive of the D sign. In settings of pressure overload, the EI will be greater than 1 in systole and diastole. In settings of volume overload, the EI is less than 1 in systole and greater than 1 in diastole (Figure 4).5

Figure 4: Eccentricity index calculation to distinguish between right ventricular pressure and volume overload. Source: Pocus 101

In this particular case, it is clear that the interventricular septal bowing is variable throughout the cardiac cycle (Figure 1-3) and the D-sign is most evident at end diastole which would suggest a ‘volume overload’ subset of RV strain. Moreover, the EI follows a pattern consistent with right ventricular volume overload, although this was not measured during the formal echo. The etiology of this volume overload RV strain may have been partly attributed by volume overload as he had an elevated JVD and a plump IVC on formal echo. However, considering the context of his recent open-heart surgery with pericarditis and evidence of RV free wall mobility limitation (Figure 3), there was higher suspicion for external compression or inflammation as the cause of his rapid onset RV dysfunction. A subsequent CT scan suggested evidence of possible pericardial clot resulting in external RV compression. The patient was subsequently scheduled for left and right heart catheterization for further assessment of cardiac pressures as a result of this new onset RV strain on ultrasound before proceeding with further surgical intervention.

This case demonstrates the utility of bedside POCUS and clarity of the D sign as a marker for right ventricular dysfunction, presents the eccentricity index as a tool for distinguishing between pressure and volume overload, and the importance of maintaining a broad differential, beyond pulmonary embolism, for the D-sign on cardiac ultrasound. 

References:

  1. Dinh V. The D Sign - Right Heart Strain from Pressure vs Volume Overload. POCUS 101, https://www.pocus101.com/the-d-sign-right-heart-strain-from-pressure-vs-volume-overload/ (accessed October 17, 2025).
  2. Cativo Calderon EH, Mene-Afejuku TO, Valvani R, et al. D-shaped left ventricle, anatomic, and physiologic implications. Case Rep Cardiol 2017; 2017: 4309165.
  3. Fields JM, Davis J, Girson L, et al. Transthoracic echocardiography for diagnosing pulmonary embolism: A systematic review and meta-analysis. J Am Soc Echocardiogr 2017; 30: 714-723.e4.
  4. Tanaka H, Tei C, Nakao S, et al. Diastolic bulging of the interventricular septum toward the left ventricle. An echocardiographic manifestation of negative interventricular pressure gradient between left and right ventricles during diastole. Circulation 1980; 62: 558–563.
  5. Ryan T, Petrovic O, Dillon JC, et al. An echocardiographic index for separation of right ventricular volume and pressure overload. J Am Coll Cardiol 1985; 5: 918–927.

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Case 66: Rapid Diagnosis of Hemorrhagic Ovarian Cyst in a Reproductive-age Patient

Brigid Larkin, Colleen Campbell

A 20-year-old female with no significant past medical history presented to the emergency department with 5 days of focal right lower quadrant abdominal pain progressively worsening in severity. The pain was constant and non-radiating, accompanied by generalized abdominal discomfort, nausea, and intermittent light-headedness. Her last menstrual period occurred 3 weeks prior. She denied vaginal bleeding, dysuria, hematuria, constipation, diarrhea, or hematochezia. Past surgical history was unremarkable. Family history was notable for uterine fibroids in her mother and maternal grandmother.

Vital signs: BP 118/67 mmHg | Pulse 89 | Temp 99.1 Fº | Resp 16 | SpO2 100%

Physical exam:  The patient was well-appearing but uncomfortable. Her abdomen was soft with mild distention and diffuse tenderness, with voluntary guarding on deep palpation. No CVA tenderness was appreciated.

Labs: Hgb 11.3, WBC 18.7, Negative urine pregnancy test, lactate WNL, Urinalysis negative

Bedside Ultrasound:

  • RUQ/Biliary: no evidence of cholelithiasis or cholecystitis
  • Appendix: no evidence of appendicitis
  • Pelvic/Transvaginal: large adnexal cyst structure (~5cm) with internal echoes suggestive of a hemorrhagic cyst; free fluid visualized in the pelvis. No evidence of intrauterine pregnancy.
Figure 1. Ovary with Adnexal Mass

A CT scan was ordered which showed a hemorrhagic ovarian cyst with mild hemoperitoneum. OBGYN was consulted and recommended no acute surgical intervention. They recommended fluids and outpatient follow-up with repeat ultrasound of right ovarian cyst at 6 weeks.

Discussion:

Acute pelvic pain in reproductive-age women represents a broad differential diagnosis including appendicitis, ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, and ruptured ovarian cyst. Point-of-care ultrasound (POCUS) serves as an essential early diagnostic tool because it is rapid, radiation free, and able to identify adnexal pathology and free intraperitoneal fluid even before CT imaging is obtained.

Hemorrhagic ovarian cysts are typically functional cysts resulting from bleeding into a corpus luteum or follicular cyst. Sonographically, they often demonstrate reticular internal echoes, a lacy or fibrin-strand appearance, or a mixed echogenicity depending on the age of the clot.1,2 Cyst rupture is more likely if the cyst is 5 cm or greater.  Color flow can be used to evaluate for active extravasation.  Symptoms accompanying rupture include sudden severe abdominal pain or near syncope.  Free fluid may be present in the pelvis, with swirling sometimes visible for brisk bleeds. Transvaginal POCUS is highly sensitive for detecting free intraperitoneal fluid of as little as 10cc, making it a valuable adjunct when evaluating patients with suspected hemoperitoneum.3

In this case, the adnexal mass with internal echoes and associated free fluid on POCUS raised concern for a hemorrhagic cyst with rupture, prompting timely gynecologic consultation and confirming findings on CT.

Hemorrhagic cysts frequently mimic appendicitis due to overlapping localization of pain and peritoneal irritation. Studies show that up to 20-30% of reproductive-age women evaluated for appendicitis ultimately have a gynecologic etiology, underscoring the importance of early pelvic imaging.4 The patient’s leukocytosis and focal RLQ tenderness initially broadened the differential, but POCUS rapidly narrowed the diagnosis.

Most hemorrhagic ovarian cysts are self-limited and managed conservatively with pain control and follow-up imaging.5 Indications for intervention include hemodynamic instability, large-volume hemoperitoneum, or concern for ovarian torsion. In this case, the patient remained stable, with moderate hemoperitoneum on CT and no evidence of torsion or persistent bleeding.  Oftentimes with cyst rupture, repeat CBC is indicated to evaluate for ongoing blood loss.

POCUS is a recommended first-line tool in the evaluation of acute pelvic pain in the emergency department. The American College of Emergency Physicians notes the utility of pelvic ultrasound for identifying adnexal masses, cyst rupture, free fluid, and excluding ectopic pregnancy in reproductive-age females.6  While transvaginal ultrasound is the standard of care for evaluation of the ovaries, transabdominal POCUS is highly effective in early triage and in resource-limited or time-sensitive settings.

This case demonstrates the significant diagnostic value of POCUS in identifying adnexal pathology early in the clinical course, guiding appropriate consultation, and avoiding unnecessary CT radiation. Recognition of characteristic sonographic features of hemorrhagic ovarian cysts empowers emergency physicians to differentiate benign from life-threatening causes of pelvic pain.

References:

  1. Jain, K. A. (2002). Sonographic spectrum of hemorrhagic ovarian cysts. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine, 21(8), 879–886. https://doi.org/10.7863/jum.2002.21.8.879
  2. Talat, H., Tul-Sughra Murrium, S. K., Suleman, T., Tallat, E., Naveed, F., Hussain Shah, S. J., & Hina Zulfiqar, G. E. (2022). Sonographic Findings of a Gynecological Cause of Acute Pelvic Pain – A Systematic Review. Journal of Ultrasonography, 22(90), e183–e190. https://doi.org/10.15557/jou.2022.0030
  3. Kimura, A., & Otsuka, T. (1991). Emergency center ultrasonography in the evaluation of hemoperitoneum: A prospective study. The Journal of Trauma, 31(1), 20–23. https://doi.org/10.1097/00005373-199101000-00004
  4. Andersson, R. E. B. (2004). Meta-analysis of the clinical and laboratory diagnosis of appendicitis. The British Journal of Surgery, 91(1), 28–37. https://doi.org/10.1002/bjs.4464
  5. Bottomley, C., & Bourne, T. (2009). Diagnosis and management of ovarian cyst accidents. Best Practice & Research. Clinical Obstetrics & Gynaecology, 23(5), 711–724. https://doi.org/10.1016/j.bpobgyn.2009.02.001
  6. American College of Emergency Physicians. Emergency Ultrasound Guidelines. ACEP;2016. https://www.acep.org/siteassets/sites/acep/media/ultrasound/pointofcareultrasound-guidelines.pdf
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