0
ONLINE EXCLUSIVES
Ultrasound Corner |

A 72-Year-Old Man Presenting With Melena and Multiple Falls Becomes Acutely DecompensatedMan With Melena Becomes Acutely Decompensated FREE TO VIEW

Ryu Tofts, MD; Pierre Kory, MD; Samuel Acquah, MD
Author and Funding Information

From Mount Sinai Beth Israel Hospital, Pulmonary Critical Care, New York, NY.

CORRESPONDENCE TO: Ryu Tofts, MD, Mount Sinai Beth Israel Hospital, Pulmonary Critical Care, 1st Ave at 16th St, 7 Dazian Building, New York, NY, 10003; e-mail: rtofts@doctors.org.uk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4):e130-e133. doi:10.1378/chest.13-1822
Text Size: A A A
Published online

A 72-year-old man was brought to the ED after passing melena for 1 day and multiple falls. The patient had recently undergone a lobectomy for non-small cell lung cancer and was recovering in a rehabilitation facility. He had a history of ischemic stroke and was taking an oral direct thrombin inhibitor. At presentation, he was conversant and hemodynamically stable, his hemoglobin level was 4.4 g/dL, international normalized ratio was 4.4, and lactate level was 2.1 mmol/L. IV access was obtained, and a Foley catheter was inserted. A nasogastric tube was placed and revealed scant coffee-ground drainage. Treatment was started with continuous infusion of IV proton pump inhibitors, and the patient received one unit of packed RBCs and two units of fresh frozen plasma. Shortly thereafter, the patient became diaphoretic, unresponsive, and tachypneic, and he demonstrated diffuse abdominal tenderness. He was intubated for airway protection. Examination revealed pallor, anuria, clear breath sounds, and a rigid abdomen. Repeated testing revealed his lactate level was elevated to 8 mmol/L, and hemoglobin level was 3.5 g/dL. A focused assessment with sonography for trauma (FAST) examination was performed to evaluate the abdominal findings and to search for a focus of bleeding. The ultrasound findings are shown in Videos 1-3.

Video 1

Epigastrium to suprapubic space

Running Time: 0:11

Video 2

Suprapubic space

Running Time: 0:09

Video 3

Right upper quadrant

Running Time: 0:15

Based on the clinical context and the ultrasound findings, what is the most likely diagnosis?
Answer: Likely diagnosis is an outlet obstruction at the level of the bladder.

Discussion Video

Discussion video

The next step is to confirm the correct placement of the urinary catheter within the bladder and replace it, if necessary. The ultrasound scan revealed a large, anechoic collection with well-defined borders with an apex in the epigastrum and an inferior border that extended into the pelvis. There was bilateral hydronephrosis but no intraperitoneal fluid or air noted. The postultrasound differential diagnosis included a possible spontaneous hematoma (rectus sheath or retroperitoneal) or massively dilated viscus (dilated bladder or small-bowel obstruction) and also cyst. Due to concern that a large hematoma might be causing abdominal compartment syndrome, a CT scan was performed, which was diagnostic of acute urinary bladder retention due to a malplaced Foley catheter (Figs 1-3). The Foley catheter was replaced, and 1.5 L of clear urine returned. The patient underwent an esophagogastroduodenoscopy the next day, which revealed a large, shallow ulcer in the duodenal bulb.

Figure Jump LinkFigure 1 –  Transverse section of the abdomen from an abdominal CT scan demonstrating a large, well-defined pelvic structure. This structure is the bladder, as seen in Videos 1 and 2.Grahic Jump Location
Figure Jump LinkFigure 2 –  Transverse section of the abdomen on CT scan. The bladder is still visible at this higher position and is extremely distended. Note the homogenous content and the well-defined borders.Grahic Jump Location
Figure Jump LinkFigure 3 –  Transverse CT image of the lower pelvis. Here, the cause of the bladder outflow obstruction is clearly identified as a kinked Foley catheter within the urethra.Grahic Jump Location

This case illustrates the importance of applying a systematic approach when investigating all ultrasound abnormalities to gather correct information to make a diagnosis (Videos 4-6). The presence of hydronephrosis should have prompted examination of the entire renal tract and ultimate confirmation of the Foley balloon in the bladder, a finding easily established on ultrasound examination (Figs 1-3, Video 6). Although the absence of the Foley catheter balloon was considered, it was erroneously attributed to being compressed from compartment syndrome and, thus, prompted a CT scan. This is the recommended next step when faced with unclear sonographic findings in a hemodynamically stable patient. In this case, the findings on CT scan produced the final diagnosis.

Discussion Video 4

well-demarcated anechoic space

Discussion Video 5

well-demarcated anechoic space

Discussion Video 6

Right upper quadrant

Since its inception in the 1990s, the use of the FAST examination protocol has assumed a central role in the evaluation of the acute abdomen. FAST scanning has been incorporated into the American College of Surgeons Advanced Trauma Life Support protocol and is, according to a 2006 survey by Moore et al,1 the most common application of ultrasonography in the ED by emergency physicians, describing 95% of all ultrasound exams performed. The principal purpose of FAST is to answer a focused set of questions, primarily: (1) Is there intraperitoneal fluid? (2) Are there gallstones? (3) Is there hydronephrosis? (4) Is there free air? (5) Is there an abdominal aortic aneurysm?

FAST is most effective when used as part of a systematic evaluation of a patient who is too unstable to tolerate extensive imaging. The sensitivity and specificity for intraperitoneal fluid detection have ranged from 75% to 100% and 90% to 100%, respectively, when a minimum of 500 mL of fluid is present.1,2 Use of FAST decreases time to disposition or surgery by 64% to 67%, and reduces CT scanning frequency, complication rates, and length of hospital stay.2 FAST scanning was slightly more sensitive and specific for penetrating traumas compared to blunt trauma, which likely reflects the fact that some blunt injuries (ie, falls, as in this case) may produce abdominal organ injury without significant bleeding. FAST scanning images the dependent areas of the abdomen in a supine patient.

The classic four probe positions for FAST are (1) hepatorenal (Morrison’s pouch), (2) epigastrum and pericardial, (3) splenorenal, and (4) the pelvic space (pouch of Douglas)3 (Fig 4). The normal and abnormal appearances of these areas are shown in Video 7 (normal appearance followed by abnormal), along with features such as gut sliding (bowel organs moving against the peritoneal wall, liver, spleen, or bowel), peristalsis of the gut, and presence and absence of fluid. The intestines are usually collapsed; however, air may exist within the bowel in normal individuals and appears as A-lines to the operator. The presence of gut sliding between the peritoneal wall and A-lines supports physiologic intraluminal air, and A-lines and absent gut sliding suggests free intraperitoneal air or scarred bowel wall adherent to the peritoneum; clinical correlation will differentiate between the two. Occasionally, clotted blood in the abdomen can be mistaken for normal surrounding tissue and although highly sensitive and specific, FAST scanning becomes even more useful when combined with CT scanning and clinical assessment.3

Discussion Video 7

Ultrasound images in the four positions

Figure Jump LinkFigure 4 –  Diagram of focused assessment with sonography for trauma (FAST) positions.Grahic Jump Location

In this case, the significant findings were a large anechoic space, absent fluid in the gut, and bilateral hydronephrosis. The differential diagnoses for these findings include cyst, bladder, and hematoma. Given the patient’s sudden decline and known coagulopathic state, a large, intraabdominal, spontaneous bleed such as an intraperitoneal bleed, rectus sheath hematoma, or retroperitoneal hematoma was a genuine concern. In both forms of intraabdominal bleeding, there is, nearly universally, a coagulopathy present and history of some form of minimal trauma (even coughing, in one case report).4 Patients usually report severe abdominal pain and a palpable mass is notable; however, some patients may present with abdominal compartment syndrome and multiorgan failure.5 The management is usually supportive with correction of coagulopathy; with abdominal compartment syndrome, surgical decompression and interventional embolization may be required.4-6 Point-of-care ultrasound is useful for making the diagnosis and appears as shown in Video 8. Differentiating blood from simple fluids like urine or uncomplicated ascites is straightforward unless the blood is acute without any coagulation present. On ultrasound, blood will usually appear as a complex anechoic space (nonhomogeneous), movement of echogenic collections may be visible, and there may be a gravity-dependent hyperechoic margin within the fluid space, representing a hematocrit sign. This can be seen on the CT scan of the same area shown in Video 8 and in Figure 5.

Discussion Video 8

Left lower quadrant

Figure Jump LinkFigure 5 –  Transverse CT section of the abdomen demonstrating a large, lower quadrant, retroperitoneal hematoma. This image corresponds to the images in Video 8. Note the heterogeneous echogenicity within a well-demarcated structure. The hematocrit sign also is seen here.Grahic Jump Location

In this case, the correct diagnosis was a massively distended bladder due to outflow tract obstruction. This was suggested on the initial ultrasound scan by the presence of bilateral hydronephrosis and an almost completely anechoic space, suggesting the presence of a simple fluid rather than blood. A key learning point in this case was that whenever hydronephrosis is found, the operator must examine the renal tract in its entirety, identify the bladder, and if there is a Foley catheter, confirm the correct position of the balloon within the bladder (Video 7). FAST ultrasound is a useful diagnostic tool that can direct intervention or further imaging. It is best used within a diagnostic algorithm to achieve its full potential.7

  • 1. Point-of-care ultrasound is useful for detecting intraperitoneal fluid and guiding clinical decision-making.

  • 2. A systematic approach to investigating all abnormalities is required to gather pertinent and correct information to make a diagnosis.

  • 3. Blood on ultrasound is usually more hyperechoic than water and there is often a hematocrit sign.

  • 4. If a urinary catheter is present, then an intrabladder balloon must be confirmed by ultrasound.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006;47(2):147-153. [CrossRef] [PubMed]
 
Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. [CrossRef] [PubMed]
 
Smith ZA, Wood D. Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability. Emerg Med J. 2014;31(4):273-277. [CrossRef] [PubMed]
 
Smithson A, Ruiz J, Perello R, Valverde M, Ramos J, Garzo L. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579-582. [CrossRef] [PubMed]
 
McBeth PB, Dunham M, Ball CG, Kirkpatrick AW. Correct the coagulopathy and scoop it out: complete reversal of anuric renal failure through the operative decompression of extraperitoneal hematoma-induced abdominal compartment syndrome. Case Rep Med. 2012;2012:946103. [PubMed]
 
Shokoohi H, Boniface K, Reza Taheri M, Pourmand A. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. CJEM. 2013;15(2):119-122. [PubMed]
 
Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. 1997;42(6):1086-1090. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Transverse section of the abdomen from an abdominal CT scan demonstrating a large, well-defined pelvic structure. This structure is the bladder, as seen in Videos 1 and 2.Grahic Jump Location
Figure Jump LinkFigure 2 –  Transverse section of the abdomen on CT scan. The bladder is still visible at this higher position and is extremely distended. Note the homogenous content and the well-defined borders.Grahic Jump Location
Figure Jump LinkFigure 3 –  Transverse CT image of the lower pelvis. Here, the cause of the bladder outflow obstruction is clearly identified as a kinked Foley catheter within the urethra.Grahic Jump Location
Figure Jump LinkFigure 4 –  Diagram of focused assessment with sonography for trauma (FAST) positions.Grahic Jump Location
Figure Jump LinkFigure 5 –  Transverse CT section of the abdomen demonstrating a large, lower quadrant, retroperitoneal hematoma. This image corresponds to the images in Video 8. Note the heterogeneous echogenicity within a well-demarcated structure. The hematocrit sign also is seen here.Grahic Jump Location

Tables

Video 1

Epigastrium to suprapubic space

Running Time: 0:11

Video 2

Suprapubic space

Running Time: 0:09

Video 3

Right upper quadrant

Running Time: 0:15

Discussion Video

Discussion video

Discussion Video 4

well-demarcated anechoic space

Discussion Video 5

well-demarcated anechoic space

Discussion Video 6

Right upper quadrant

Discussion Video 7

Ultrasound images in the four positions

Discussion Video 8

Left lower quadrant

References

Moore CL, Molina AA, Lin H. Ultrasonography in community emergency departments in the United States: access to ultrasonography performed by consultants and status of emergency physician-performed ultrasonography. Ann Emerg Med. 2006;47(2):147-153. [CrossRef] [PubMed]
 
Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Ann Emerg Med. 2006;48(3):227-235. [CrossRef] [PubMed]
 
Smith ZA, Wood D. Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability. Emerg Med J. 2014;31(4):273-277. [CrossRef] [PubMed]
 
Smithson A, Ruiz J, Perello R, Valverde M, Ramos J, Garzo L. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579-582. [CrossRef] [PubMed]
 
McBeth PB, Dunham M, Ball CG, Kirkpatrick AW. Correct the coagulopathy and scoop it out: complete reversal of anuric renal failure through the operative decompression of extraperitoneal hematoma-induced abdominal compartment syndrome. Case Rep Med. 2012;2012:946103. [PubMed]
 
Shokoohi H, Boniface K, Reza Taheri M, Pourmand A. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. CJEM. 2013;15(2):119-122. [PubMed]
 
Branney SW, Moore EE, Cantrill SV, Burch JM, Terry SJ. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. 1997;42(6):1086-1090. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543