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急診超音波在
下腹部和骨骼軟組織的應用
陳國智醫師
新光醫院急診醫學科
輔仁大學醫學系
中華民國醫用超音波學會指導醫師
1
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Lower abdominal echo
2
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Scenario
25 y/o female
C/O: acute low abdominal pain
w/ cold sweating, VAS: 8/10
BP: 60/40 mmHg; HR: 130 bpm
Menstruation: 2nd day
Your impression ?
Next step ?
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2008 ACEP EUS guidelines
• Describe the relevant local anatomy of pelvic cavity
• Describe the role of focused US in first-trimester pregnancy pain and bleeding.
• Understand the role of US and quantitative β-hCG in a clinical algorithm for first-
trimester pregnancy pain and bleeding.
• Understand the differential diagnosis of early pregnancy including intrauterine
pregnancy, embryonic demise, molar pregnancy, ectopic pregnancy, and
indeterminate classes.
• Recognize the relevant focused findings and pitfalls when evaluating for early
intrauterine pregnancy and ectopic pregnancy.
– Early embryonic structures
– Location of embryonic structures in pelvis
– Findings of ectopic pregnancy
– Pseudogestational sac
– Adnexal masses
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Role of EUS for OB/GYN
• Identify an IUP
• Establish fetal viability
• Hemodynamic instability in a female patient
• Trauma and pregnancy
• Localization of IUD/foreign body
• Identify sources of pelvic pain and bleeding in
pregnant & non-pregnant patients
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Trans-abdominal US 1st choice for emergency physician
• Use a lower frequency transducer: 3.5 –5 mHz
• Better penetration, larger field of view
• It should be the initial imaging window to assess
for
– Advanced IUP
– Fibroids/masses
– Pelvic fluid
• The bladder should be full to provide an acoustic
window
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Transvaginal US
• Use a higher frequency transducer: 6.0-7.5mHz
• Provides optimal imaging of:
– Endometrium
– Myometrium
– Cul-de-sac
– Ovaries
• A full bladder is not necessary for this approach
• Is usually better tolerated by patients
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Normal Pelvic Anatomy
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Trans-Abdominal Scan
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Normal Pelvic Scan
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TVS: Sagittal View
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Pelvic Scan (TVS)
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TAS versus TVS
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Pelvic Sagittal View
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US Findings in IUP
• Gestational sac
• Double decidual sac sign (DDSS)
• Yolk sac
• Embryo
• Cardiac activity
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Intradecidual Sign
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Gestational Sac
• Anechoic area within the uterus
surrounded by two bright echogenic rings
– Decidua vera (the outer ring)
– Decidua capsularis (the inner ring)
• This is referred to as the double decidual
sac sign (DDSS)
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Double Decidual Sign
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Yolk Sac
• First embryonic structure that can be
detected sonographically
• Visualized approximately 5-6 weeks after
the last menstrual period
• Bright, ring like structure within the GS
• Should be readily seen when the GS sac
is greater than 10 mm (using EVS)
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Yolk Sac
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Embryo & Yolk Sac
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Intrauterine embryo & yolk sac
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Intrauterine fetus
and yolk sac & amnion
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A Fetal Heart Beat
• An important prognostic indicator
• The rate of spontaneous abortion is extremely low (2- 4%) after the detection of normal embryonic cardiac activity
• The normal fetal heart rate in early pregnancy is 112-136
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43F complained low
abdominal pain
What do you see ?
26
Ectopic pregnancy
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Ectopic Pregnancy
• 2% of all pregnancies, 7-13% of those who
present with pain or bleeding
• Incidence quadrupled in last 20 years
• 50% were missed before widespread use
of ultrasound
• Still the #1 cause of maternal death in
1st trimester
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Rule-out Ectopic Pregnancy
(saves time and money)
• Find an IUP
• Chance of both IUP and EP is 1/8000
• As high as 1/100 if pt takes fertility agents
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β-hCG Levels
• Correlate roughly with gestational age
• Older algorithms relied on β-hCG
• One level means almost nothing
• Serial levels are helpful
• 40% ectopics have a β-hCG level <1000
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Discriminatory Zone
• Def:
– The level of β-hCG at which findings of an
IUP are expected on sonography
• Titinalli 7th ed.
– TVS 1500 mIU/mL; TAS 6000 mIU/mL
• Rosen
– TVS 3000 mIU/mL; TAS 6500 mIU/mL
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ß-hCG >discriminatory zone and empty
uterus is EP until proven otherwise
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Sonographic Spectrum of EP • Ruptured ectopic pregnancy
• Definite ectopic pregnancy
• Extrauterine empty gestational sac
• Adenexal mass
• Pseudogestational sac
• Empty uterus
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Empty uterus & free fluid in CDS
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Empty Uterus & Complex fluid in CDS
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Empty Uterus &
Free fluid in CDS & hepatorenal space
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39F_33wk + ABD pain
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Molar pregnancy
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Estimation of GA
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Pregnancy Dating
Crown Rump Length (CRL)
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Biparietal Diameter
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Femur Length
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Fetal Heart Rate Determination
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Location of appendix
Pregnancy 18wks & 30wks & Appendicitis
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Main Goals in Non-pregnant
Patients • Determining the etiology of abdominal pain -
pelvic organs or other etiology
• Hemorrhagic ovarian cyst
• Ovarian torsion
• Ovarian hyperstimulation syndrome (OHSS)
• Tubo-ovarian abscess
• Fibroid (Leiomyoma)
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Ruptured corpus luteum cyst
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16F with low abdominal pain
Pregnancy test: negative
What do you see ?
49
Ruptured ovarian cyst with internal bleeding
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18F with low abdominal pain
What do you see ?
51
Pelvic Tumor
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16F with severe low
abdominal pain
What do you see ?
52
Hematometria
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47F with low abdominal pain
What do you see ?
53
Teratoma
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39F with fever and low
abdominal pain
What do you see ?
54
TOA & Pyosalpinx
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Graded compression technique
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GI tract lesions on sonography
1. 腸胃道壁增厚 (>4mm)
2. 腸胃道壁分層消失
3. 蠕動減少
4. 用超音波探頭壓迫時不變形
5. 病灶通道內容物減少
6. 病灶附近之其他變化(LN, fat, ascites)
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Alvarado Score
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Question
• 請問下列何者非急性闌尾炎的超音波發現 ?
1. Blind-ended tubular structure
2. Non-compressible appendix
3. Diameter > 6mm
4. Dome sign
5. Appendicolith
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Appendicitis
Eur Radiol. 2002;12:1748-61
• Diameter > 6mm (Cross section)
• Non-compressiblity of appendix
• Localized pain during compression with the transducer
• Alteration of the periappendiceal fat
(echogenic & non-compressible fat)
• Obstruction of the lumen by an appendicolith
• Hypervascularizaion in color Doppler of appendix and surrounding fat
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Landmark of Appendix
• RLQ
– Iliac crest
– Psoas muscle
– Iliac vessels
– Cecum & A-colon
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Cecum, Ileum and Appendicitis
Appendicitis with obvious cecum and ileum
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Appendicolith
Appendicitis with appendicolith
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10M with low abdominal pain
What do you see ?
65
Ruptured appendicitis
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14M with low abdominal pain
What do you see ?
66
Ruptured appendicitis with abscess and ileus
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47M with RLQ and low
abdominal pain
What do you see ?
67
Ruptured appendicitis
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27F, pregnancy at 14 wk
RLQ pain
What do you see ?
68
Appendicitis
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21M with RLQ pain
What do you see ?
70
Cecal diverticulitis
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問題
• 請問下列何者為大腸憩室炎的超音波發現 ?
1. Corona sign
2. Target sign
3. Curtain sign
4. Dome sign
5. Veiled Kidney sign
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21M with RLQ pain
Cecal diverticulitis
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Dome sign:
acute colonic diverticulitis
J Clin Ultrasound. 2000;28:340-6.
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Copyright © Radiological Society of North America, 2003
O'Malley, M. E. et al. Radiographics 2003;23:59-72
Right-sided diverticulitis in a 32-year-old woman
with right lower quadrant pain and fever
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48M with right abdominal pain
A-colon diverticulitis
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18M with RLQ pain
Cecal diverticulitis
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25F with LLQ pain
S-colon diverticulitis
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26F with RUQ pain
A-T colon junction diverticulitis
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32M with RLQ pain
Terminal ileum diverticulitis
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39F with LLQ pain
What do you see ?
80
Left UVJ stone
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59M, left flank pain & hematuria
82 Ruptured AAA
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69M, diffuse low abdominal pain Difficult voiding and defecation for two weeks
84
Colovesicular fistula
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95M, abdominal pain with bloody
ascites
85 Bladder rupture
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Soft tissue & MSK echo
86
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請問超音波在MSK的應用不包含下列何者
1. 診斷蜂窩性組織炎
2. 辨識肢體腫脹是否為深部靜脈栓塞所致
3. 尋找異物
4. 診斷關節處骨折
5. 辨識是否有軟組織膿瘍
87
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Outlines
• US anatomic considerations
• Skin and soft tissue infection
• Long Bony fracture evaluation
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正常組織超音波影像 • Skin
– Echogenic
• Subcutaneous tissue – Hypoechoic
– Traverse by irregular strands of hyperechoic connective tissue
• Fascial planes – Hyperechoic; regular thickness
• Muscles – Striated appearance on long axis scan
• Tendon – Fibrillar; echogenic
• Vascular structures – Anechoic (Artery versus Vein)
• Lymph nodes – Irregular, circular, echogenic; with hypoechoic rim
• Bones – Echogenic cortices and dense acoustic shadows
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掃描注意事項
• 高解析線形探頭 (5-10MHz)為第一首選
• 注意深度(depth)和焦點(focus)的設定
• 適當應用探頭施壓
• 至少掃描兩個介面 (longitudinal & transverse)
• 考慮和對側比較 & 呈現在同一畫面 (Split screen)
• 如何改善掃描品質 – Stand-off pad
– Water/gel-filled glove
– Water bath technique
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EUS在皮膚 & 軟組織感染的應用
• 須熟悉正常超音波軟組織影像
• 認識週遭組織及結構
• 協助設定最佳切除及引流路徑
• 正確診斷不明顯膿瘍
診斷
• 正確定位不明顯膿瘍
定位
• 協助膿瘍引流
處置
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皮膚 & 軟組織感染
• Cellulitis – Cobblestone-like appearance
• Subcutaneous abscess – Variable appearance
– Most: hypoechoic; spherical mass
– Content: • Hyperechoic sediment
• Septae
• Gas
• Isoechoic or hyperechoic
• Liquefied pus – induced motion of the
content
• Necrotizing fasciitis – Marked thickened of SC layer
– A layer of anechoic fluid, • greater than 4 mm
• adjacent to deep fascia
– Subcuatneous gas • Acoustic shadow
• Reverberation artifact
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Cellulitis
• Nonspecific
• Indicative of edema
• Skin
• Subcutaneous tissue
• Compare to unaffected side
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Normal v.s. Cellulitis
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EUS improves accuracy of superficial
abscess detection
Squire BT, et al. AEM. 2005;12:601-606
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NTUH experience
• diffuse thickening of the SC tissue
• a layer of fluid accumulation more than 4 mm in depth along the deep fascial layer
• 66 patients (17,NF)
• Sensitivity: 88.2%
• Specificity: 93.3%
• PPV: 83.3%
• NPV: 95.4%
• Accuarcy: 91.9
Yen ZS, et al. AEM. 2002;9:1448-1451
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EUS for DVT survey
• Primary component
– Visualize the venous structures
– Detect gray-scale compressibility
– Lack of compressibility DVT
• Secondary component
– Use of Doppler to evaluate for abnormal flow
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No complete compression
1. Presence of a clot
2. Inadequate pressure on the
transducer
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骨折評估
• 肋骨骨折
• 胸骨骨折
• 長骨骨折
• 堅困環境骨折
• 骨折復位
• 脫位復位
• FASTER
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骨折評估
• 骨表面產生不連續線條
• 骨折周圍低回音血腫
• 掃描時注意最痛點
• 至少進行兩個介面掃描
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Rib
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Rib fracture
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Normal sternum
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Sternal body fracture
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Femur
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Tibial shaft fracture
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50M with abdominal pain
What do you see ?
113
Urachal cyst abscess
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42F, low abdominal pain
What do you see ?
114
Abdominal wall hematoma
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54F with fever and painful
back mass
What do you see ?
115
Back carbuncle
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58M s/p thyroidectomy
116
Neck abscess
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56M with left thigh pain
What do you see ?
117
Lymphadenopathy
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75M with anal pain and fever
What do you see ?
118
Perianal abscess
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19M,打橄欖球受傷
120 Shoulder dislocation and reduction
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78F with fever and right hip pain
121
Septic arthritis
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Take Home Message
• Know anatomy
• Find landmark
• Recognize patterns