Ultrasound Case 024

Presentation

41 year old female with a history of liver cirrhosis and ascites. She is anticoagulated for Budd-Chiari syndrome and presents with hypotension and right lower quadrant pain.

Image 1 _ Right upper quadrant _Longitudinal_hepatorenal recess_ Case 24
Right upper quadrant FAST view
View 2 – Right upper quadrant, coronal view
Image 2_ Right upper quadrant_ longitudinal_Case 24
View 3 – Right abdomen, transverse view
Image 3 _ Right upper quadrant_ Transverse Case 24
View 4 – CT abdomen

Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Right upper quadrant FAST view; There is a complex cystic structure with internal loculations. There is some ascites and an incompletely visualized cystic structure involving the upper pole of the right kidney.

Image 2: Right upper quadrant, coronal view; Again there is a large complex cystic structure with numerous internal loculations. There is fine dependent, layering echogenic debris that has a relatively homogeneous ground glass appearance.

Image 3: Right abdomen, transverse view. The gravity dependent hyperechoic debris is again seen.

Fine layering echogenic debris is generally blood or pus. In this case with rapid onset, no features of infection and in an anticoagulated patient blood is almost certainly the cause. The structure is rounded and appears contained rather than free. Retroperitoneal bleeding or a contained intraperitoneal bleed are likely.

Image 4: This is a CT scan of the same patient.


CLINICAL CORRELATION

Retroperitoneal haemorrhage in anticoagulated patient.

Ultrasound has a poor sensitivity for diagnosing retroperitoneal haemorrhage, but in this patient the huge retroperitoneal collection is easily visualized.

CT confirmed this was a large retroperitoneal haemorrhage displacing the right kidney cranially, with ongoing active bleeding.

There was also a large amount of ascites.


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Michael Bogseth, MD. Ultrasound Fellow in Emergency Medicine. American Board of Emergency Medicine Diplomate | @mbogs001 | LinkedIn |

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