Emergency Ultrasound Course For Radiologists.

1. Emergency Ultrasound Course
Urgent Sonographic signs – Part-2
By:
Dr/ Ismail Sayed Ismail
Radiologist
is
Great doctor

2. Sonographic signs of inflammation / edema, …
1. Fat edema (ECHOGENIC FAT is the most
Significant Single Sonographic Sign of Inflammation).
2. Free air.
3. Interstitial edema.
4. Free fluid.
5. Reactive lymph nodes.
6. Reactive ileus (in abdominal inflammation).
7. Specific features (differs according to
organ or area of inflammation).
Echogenic Fat is
your best friend
in U/S emergencies

3. Echogenic fat ? Degree of echogenicity / brightness
Center of echogenicity / Max. brightnessSpecific features
Password
ECHOGENIC FAT

4. Sonographic signs of inflammation / edema, …
1. Fat edema (ECHOGENIC FAT is the most
Significant Single Sonographic Sign of Inflammation).
2. Free air / air in abnormal location.
3. Interstitial edema / Sc edema / Skin edema.
4. Reactive fluid / Free fluid.
5. Reactive lymph nodes / Non-specific LN.
6. Reactive ileus (in abdominal inflammation).
7. Specific features (differs according to
organ or area of inflammation).
Echogenic Fat is
Not alone. Look for
additional urgent
sonographic signs

5. 2. Free air / air in abnormal location
• Where to look ?
– In case of perforation, an air-track can be found from the ulcer / bowel
to the peritoneal cavity usually in ventral or cranial direction.
– Localized air collection may be seen in abscess formation.
Moderat
e Fl. + air
loculiFree air
superficial
to liver
Perforated peptic ulcer
with Pneumoperitoneum
Perforated appendix
with appendiceal abscess

6. • Where to look ?
– Free air is best demonstrated in the supine or left decubitus position
between liver and right abdominal wall.
– Wait for few minutes ?

7. • What to look for ?
– Echogenic foci / lines between the surface of the liver and anterior
abdominal wall.
– With comet tail or reverberation artifacts.
– Mobile on dynamic study.

8. • Pneumoperitoneum.

9. • Pneumoperitoneum.

10. • Pneumoperitoneum.

11. • Pneumoperitoneum.

12. • Pneumoperitoneum.
• Enhanced peritoneal stripe sign.

13. • Curtain sign ?

14. • Echogenic foci with comet tail artifacts = air in abnormal location.
• What else ?

15. • Echogenic foci with comet tail artifacts = air in abnormal location.
• What else ?

16. • Echogenic foci with dirty shadow artifacts = air in abnormal location.
• What else ?

17. • Echogenic foci with comet tail artifacts = air in abnormal location.
• What else ?

18. 3. Interstitial / subcutaneous / skin edema
• Appearance.
– Interlacing hypoechoic lines > giving it cobble-stone appearance.
– May be associated with hyperaemia and echogenic fat as in cellulitis,
(clinically : hotness, redness, tenderness, …).
– May be associated with localized fluid
collection as in abscess.
– Esp. important in post-operative patients.

19. • SC edema.

20. • SC edema.

21. • Skin edema.

22. • SC edema with air – where ?

23. 4. Reactive fluid
• Amount & Aspect.
• Usually free, clear of minimal amount, seen in the vicinity of inflamed organ.
• If the amount is increased and localized, think of abscess formation.
• If becomes turbid, think of perforated viscus / abscess formation.
• If associated with floating linear echogenic foci (air), think of abscess.
Moderate Fl. + air loculiMinimal Fl. in Morrison

24. – It appears as minimal clear ascites as in cases of inflamed intra-peritoneal
structures, acute appendicitis, acute sigmoid diverticulitis, …
– It may surround an inflamed retroperitoneal structure, as minimal
perinephric collection / minimal rim along psoas muscle can be seen in
acute pyelonephritis, acute pancreatitis, ...
Minimal Fl. in Perinephric
space as in Pyelonephritis
Minimal Fl. Along Psoas
as in Pancreatitis, PN, AAA

25. 5. Reactive lymph nodes
1. Appearance.
– Non-specific = Reactive L.N = preserved oval shape, central echogenic
fatty hila, central hilar vascularity, ...

26. 1. Appearance.
– Specific = Pathological L.N = hypoechoic LN, central caseation,
peripheral hyperechoic / fatty hypertrophy, matted LN, …
Specific LN
Tuberculous mesenteritis
Non-specific LN
Reactive mesenteric adenitis

27. 2. Distribution.
– Usually in the vicinity of the inflamed organ, as right iliac fossa reactive
mesenteric lymph nodes in cases of acute appendicitis.
– May be seen at the proximal drainage site, as inguinal lymph nodes in
lower limb cellulitis, abscess, ....

28. 3. When to say >> Primary Adenitis (mesenteric adenitis).
– May be seen as a separate entity, as
mesenteric adenitis, ONLY if associated
with normal sonographic appearance of
the appendix.

29. 6. Reactive ileus (in acute abdomen)
1. Appearance.
– Sentinel loop.
– Usually mildly dilated fluid–filled (fluid–filled in ultrasound or air–filled
in plain x-ray) hypoperistaltic / aperistaltic bowel loop.
– Usually in the vicinity of the inflamed organ,
as right iliac fossa in acute appendicitis,
left iliac fossa in acute diverticulitis,
central in acute pancreatitis, …

30. 2. Distribution.
– Usually in the vicinity of the inflamed organ, as right iliac fossa in acute
appendicitis, left iliac fossa in acute diverticulitis, central in acute
pancreatitis, …

31. 3. When to say >> intestinal obstruction.
– Strong clinical suspicion, absolute constipation, significant distension,
previous operation, …
– Dilated fluid-filled evenly distributed bowel loops, fluid in-between,…
Peristalsis …

32. 7. Specific features
• Differs according to inflamed organ / area.

33. Summary
Fat edema
Echogenic fat
Reactive ileusInterstitial edema
Free air Reactive nodesFree fluid

34. Introduction to
Bowel Ultrasound