8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 1/78

Vascular emergencies &

 Appendicitis

  新光醫院急診醫學科 

 陳國智醫師   中華民國醫用超音波學會指導醫師 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 2/78

Vascular emergencies

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 3/78

Question

• 請問腹主動脈瘤診斷標準，直徑需為多少 ?

1. 大於2公分 

2.

大於3

公分 

3. 大於4公分 

4. 大於5公分 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 4/78

 Anatomy and Probe position

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 5/78

Transverse View

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 6/78

Transverse View

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 7/78

Longitudinal View

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 8/78

Coronal View

  傳統view  看不見時的輔助介面 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 9/78

ObstaclesBowel gas

Obesity

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 10/78

The cylinder tangent effect

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 11/78

Question

• 請問急診超音波在主動脈急症的應用最重  要的目的為何 ?

1.

診斷有無胸部主動脈瘤 

2. 診斷有無腹部主動脈瘤 

3. 診斷有無主動脈瘤破裂 

4. 診斷有無主動脈剝離 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 12/78

59M with hematuria and flank pain

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 13/78

SKHER AAA protocol

•  Any patient: age >= 50 y/o

 – Syncope / hypotension/dizziness and/or 

 –  Abdominal / back / flank / groin pain

• EUS – Abdominal aorta evaluation

 – Subxiphoid area, longitudinal & transverse

 – From just below diaphragm to bifurcation

 – Epigastrium, SMA, and 3cm above bifurcation

 –  AAA: diameter more than 3cm (>=5cm, high risk)

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 14/78

59M with hematuria and flank pain

 AAA 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 15/78

76M with abdominal pain

 AAA, impending rupture

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 16/78

65F with mid-abdominal pain

 Aortic dissection with flap

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 17/78

78M with AAA s/p grafting, Abdominal pain

Ruptured AAA

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 18/78

69M with chest pain and shock

• 請問此患者最可能是  那種型態的休克 ?

1. Hypovolemic shock

2. Obstructive shock

3. Cardiogenic shock

4. Septic shock

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 19/78

69M with chest pain and shockHemopericardium by aortic dissection

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 20/78

84F IHCA during ERCPHemopericardium by aortic dissection 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 21/78

91F with right thigh swelling for 3 d

• 請問造成左圖大腿病灶最可能的原因為何 ?

1. Abscess

2. Pseudo-aneurysm

3. DVT

4. Tumor 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 22/78

91F with right thigh swelling for 3 d

Pseudo-aneurysm

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 23/78

81F with left thigh ecchymosis

 AV fistula

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 24/78

59M with right arm painful swelling

Pseudo-aneurysm

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 25/78

DVT   臨床表徵  

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 26/78

Clinical assessment model:

Wells criteria

Active cancer (treatment ongoing or within previous 6 months or palliative) 1

Paralysis, paresis or recent plaste, or immobilization of lower limbs 1

Recently bedridden for 3 days or more, or major surgery < 4 weeks 1

Localized tenderness along the DV system distribution 1

Entire leg swollen 1

Calf swelling > 3cm compared with asymptomatic leg (10cm below the tuberosity) 1

Pitting edema 1

Collateral superficial veins (nonvaricose) 1

Previously documented DVT 1

Alternative diagnosis as likely or greater than DVT -2

Low probability 0

Moderate probability 1-2

High probability 3

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 27/78

Question

• 請問診斷深部靜脈栓塞的最主要依據為何?

1. 掃描部位的靜脈若能完全壓遍即可排除 

2.

掃描部位的靜脈是否在Doppler 

 下有血流 

3. 掃描部位的靜脈是否有看到栓塞(thrombus)

4. 必需使用具備Doppler 功能的儀器才能在臨床上應用 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 28/78

EUS for DVT

• Non-compression of the vessel

 – Inability to completely compress the vessels

 –With proper pressure

 – After ensuring good position

• FYI:

 –

 –

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 29/78

Landmark for DVT Scan

• Mid-point of inguinal ligment – Vessels: CFV & CFA

 – Until CFV splits into DFV & SFV (Mid-thigh)

• Popliteal fossa

 – Vessels: PV & PA – The last 2 cm of PV and end just distal to the trifurcation

 – “ the vein comes to the top in the pop” 

• Contralateral leg scanning – Optional

• Documentation – Dual-image feature: w/ & w/o compression

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 30/78

No complete compression

1. Presence of a clot

2. Inadequate pressure on thetransducer 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 31/78

Methods to extend veins

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 32/78

Ideal transducer 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 33/78

Scanning technique

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 34/78

Position for femoral area

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 35/78

Effect of Compression

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 36/78

Popliteal area

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 37/78

DVT

• EUS

 – Can tell you the presence or absence of 

proximal DVT

 – Can’t tell you• the presence or absence of distal DVT

• the cause of the pain if the US is normal

•Two point compression approach

• Look for 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 38/78

Question:  請問有無DVT ?

 有 (1)無 (2)

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 39/78

72F with left leg swelling and pain

for 2 days; BT: 38.5℃ 

Q ti 有無DVT ?

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 40/78

Question: 有無DVT ?

 有(1)

無(2)

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 41/78

DVT

• Criteria:

1. Non-compressible vein

2. Echogenic thrombus

Question:有無DVT ?

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 42/78

Question: 有無DVT ? 有 (1) 無 (2)

Mid-thigh DVT

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 43/78

59M, right leg swelling for 3 days

DVT

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 44/78

Question:  請問那邊有DVT ?

64F with left leg pain and swelling DVT ??

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 45/78

64F with left leg pain and swelling, DVT ??

  是 (1)  否 (2)

Lymphadenopathy

83M with left leg pain DVT ??

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 46/78

83M with left leg pain, DVT ??  是 (1)  否 (2)

Baker’s cyst rupture 

66M ith i ht lli

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 47/78

66M with right arm swelling

Subclavian vein thrombosis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 48/78

88F with abdominal pain

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 49/78

Volvulus ( Whirlpool sign)

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 50/78

77F with refractory abdominal pain

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 51/78

SMA occlusion

53F i h i ith bd i l i

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 52/78

53F, cirrhosis with abdominal pain

SMV thrombosis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 53/78

 

 Appendicitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 54/78

Graded compression technique

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 55/78

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)

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 56/78

 Alvarado Score

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 57/78

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

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 58/78

 Appendicitis

Eur Radiol. 2002;12:1748-61

• Diameter > 6mm (Cross section)

• Non-compressiblity of appendix

• Localized pain during compressionwith the transducer 

•  Alteration of the periappendiceal fat

(echogenic & non-compressible fat)

•

Obstruction of the lumen by anappendicolith

• Hypervascularizaion in color Doppler of appendix and

surrounding fat

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 59/78

Landmark of Appendix

• RLQ

 – Iliac crest

 – Psoas muscle

 –

Iliac vessels – Cecum & A-colon

A di l t di t f

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 60/78

 Appendiceal outer diameter for 

appendiceal mucocele VS appendicitis

Lien WC, AJEM (2006) 24, 801 –805

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 61/78

Cases

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 62/78

Cecum, Ileum and Appendicitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 63/78

 Appendicolith

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 64/78

11M with appendicitis

27F Pregnancy 14wks

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 65/78

27F, Pregnancy 14wks,

 Appendicitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 66/78

Lateral appendicits

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 67/78

學習認 Landmark

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 68/78

Ruptured appendicits

10M with peritonitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 69/78

10M with peritonitis

Ruptured appendicitis

14M with peritonitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 70/78

14M with peritonitis

Ruptured appendicitis 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 71/78

45F with RLQ pain 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 72/78

Ruptured retrocecal appendicitis

* 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 73/78

47M with RLQ pain 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 74/78

Ruptured appendicitis

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 75/78

66M with RLQ pain

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 76/78

 Appendiceal mucocele

57F with mid-abdominal pain

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 77/78

57F with mid abdominal pain

 Appendicitis around umbilicus

* 

* 

8/4/2019 Vascular emergencies & Appendicitis@

http://slidepdf.com/reader/full/vascular-emergencies-appendicitis 78/78

  謝謝聆聽  

  歡迎指教及給予回饋 

Juice119.pixnet.netJuice119@gmail.com