POCUS can rapidly and effectively evaluate many causes of abdominal pain. It can identify liver abnormalities like hepatitis or cirrhosis. The gallbladder and common bile duct can be examined for issues like cholecystitis or gallstones. Appendicitis is detectable by viewing an enlarged, non-compressible appendix. Small bowel obstructions appear as dilated bowel loops with reduced peristalsis. Free fluid and pneumoperitoneum can indicate internal bleeding or perforation. POCUS is a valuable tool for emergency evaluation of abdominal pain.

1. Evaluation abdominal pain
by point of care ultrasound
Tutor: Lei Man Sang
IC: Lam Ian Seng

2. Content
 Introduction
 What is point of care ultrasound
 Abdominal Ultrasound Preparation
 Liver ultrasound
 Gallbladder, Common Bile Duct Ultrasound
 Appendix Ultrasound
 Small Bowel Obstruction Ultrasound
 Pneumoperitoneum Ultrasound

3. Introduction
 Abdominal pain is the chief complaint in 5 to 10 % of emergency department visits, and
patients often require extensive evaluations, including history taking, physical examination,
blood test and imaging. The differential diagnosis is wide, ranging from benign to life-
threatening conditions.

4. Rapid assessment for abdominal pain
 The evaluation starts with obtaining a history and performing a physical examination.
 We simultaneously and rapidly assess if the patient may be having a life-threatening abdominal pain.
Potential indicators include shock ,presence of peritonitis, significant distress from pain, altered
mental status.

5. Physical examination

6. Point of care ultrasound
Point of care ultrasonography (POCUS)is advanced diagnostic ultrasonography that is performed by the
attending doctor as a bedside test. POCUS has been widely used in many disciplines as a rapid diagnostic tool.
POCUS has been used to aid the diagnosis of multiple medical conditions ranging from acute appendicitis,
abdominal aortic aneurysm, traumatic injury assessment.
There are several advantages of incorporating POCUS in daily clinical practice, with the major one being
integrating sonographic findings with history and clinical examination at the patient's bedside.

7. Point of care ultrasound
 POCUS use and implementation have expanded significantly over the past 15 years. Despite
being widely used across different medical specialization.
 In France, POCUS availability in the emergency department was as high as 71% in 2016.
 In Danish, more than 80% of the emergency departments, POCUS has been available to
emergency doctor.
 In Canada, general and emergency doctor, access to POCUS has increased from 60% access in
2013 to more than 90% access in 2019.
 In the USA, ultrasound training is now integrated into EP training.
 In China, more than half of emergency department physicians have reported having access
to POCUS, with 43% reporting using it in their clinical work.

8. Abdominal Ultrasound Preparation
 Patient Preparation
 Your patient should be supine with the head of the bed flat.
 Ask the patient to bend their legs at the knees to help relax
the abdominal muscles.
 Transducer: Usually curvilinear Probe.

9. Liver ultrasound

10. Liver ultrasound
 Using the lateral ultrasound approach, assess the size, parenchymal
echogenicity, and surface characteristics of the liver.
 A healthy liver should be < 16cm in this dimension.

11. Liver ultrasound
 Assess the liver’s echogenicity and capsular contour.
 Normally, the liver has a homogenous echogenicity similar
to the renal cortex.
 The liver should have a smooth capsular contour, similar
to that of the kidney.
This liver measures 12.6cm in the craniocaudal dimension

12. Acute hepatitis: Chronic hepatitis/cirrhosis: Fatty Liver Disease
↑ Brightness of portal vein
walls
↓ Brightness of portal vein walls ↓ Brightness of portal vein
walls
↓ The echogenicity of the
liver
↑ Liver echogenicity ↑ Liver echogenicity
Usually Enlarged Liver Usually Small/Atrophic Liver Usually enlarged Liver

13. Acute Hepatitis Ultrasound Findings
 Acute hepatitis occurs when the liver has an inflammatory reaction to an injury, whether traumatic,
infectious, drug-induced, or autoimmune.
 Hepatomegaly is the most sensitive US finding in acute hepatitis, defined as a craniocaudal length ≥
16.0cm in the midclavicular line.
 In addition, the liver may appear relatively hypoechoic, due to inflammatory fluid buildup in acute
hepatitis.

14. Acute Hepatitis Ultrasound Findings

15. Cirrhosis Ultrasound Findings
 The liver will be hyperechoic relative to the right kidney.

16. Liver abscess
Liver abscesses is defined as a pus-filled mass in the liver.

17. POCUS present a sensitivity between 85~92%
of the liver abscess.

18. Gallbladder & Common Bile Duct
Ultrasound

19. Gallbladder & Common Bile Duct Ultrasound
 Ultrasound is the first choice.
 Position the probe in the epigastric midline.
 In the midline, you will likely see the Main
Portal vein in the long-axis, proximal to when
it curves into the liver.

20. Gallbladder & Common Bile Duct Ultrasound
 Slide laterally along the costal margin, toward the patient’s right, until you
can clearly see the Portal Triad (Portal vein, Hepatic Artery, and Common Bile
Duct) in short axis.

21. Measure the anterior gallbladder wall thickness.
 Measure the anterior gallbladder wall thickness.
 The normal anterior gallbladder wall thickness is <3mm.

22. Evaluate the Common Bile Duct
 Return to the short-axis view of the portal
triad (“Mickey Mouse Sign”).
 Use color Doppler to distinguish the common
bile duct from the hepatic artery.
 Flow will be seen in the hepatic artery, while
the common bile duct will remain anechoic
with no pulsatile flow.

23. Evaluate the Common Bile Duct
 Visualize the common bile duct in the long axis and
measure the anteroposterior diameter.
 Measure it from inner wall to inner wall.
 A normal CBD measurement is <5mm.
 Patients that have had their gallbladder removed can
have normal CBD measurements of <10mm.

24. Cholelithiasis
 Ultrasound is the gold standard for the detection of gallstones, which will
appear as highly hyperechoic collections with posterior shadowing within the
gallbladder lumen. The stones may be move within the lumen when the
patient changes position.

25. Cholecystitis on Ultrasound
 A Sonographic Murphy sign, however, refers to the presence of maximal tenderness when
ultrasound probe pressure is applied over the visualized gallbladder on ultrasound. This is
a very sensitive finding for cholecystitis.
 Important secondary findings include gallstones, anterior gallbladder wall thickening
>3mm, pericholecystic fluid.

26. Gallstones during POCUS with positive Murphys sign has a 92%
positive for acute cholecystitis. If the US shows a normal
gallbladder wall, acute cholecystitis can be ruled out.

27. Choledocholithiasis
 On ultrasound, look out for calculi in the gallbladder or CBD, and a dilated
common bile duct. Any CBD wider than 5mm should raise suspicion.

28. Appendix Ultrasound

29. Appendix Ultrasound
 The appendix is located in the right lower quadrant, attached to the cecum.
However, its location can vary widely in its anatomic position.

30. Appendix Ultrasound
 Two ways to go about the appendix POCUS exam.
 1. Point of maximal tenderness.
 2.Systemic approach, try starting in the RUQ, trace the ascending colon
downward until reaching the cecum, and have identified the psoas major and
the iliac vessels, search slightly medial to the psoas muscle for the
appendicitis.

31. Appendicitis Ultrasound Findings
 Non-compressibility of the appendix (unless perforated);
 Blind ended pouch;
 Diameter of the appendix > 6 mm;
 Single wall thickness ≥ 3 mm;
 Target sign;
 Hyperechoic appendicolith with posterior shadowing.
Dilated appendix with blind ended Pouch Appendicolith in an appendix with a diameter > 6cm.
Dilated appendix with a diameter >6mm and “Target Sign”

32. A meta-analysis showed that POCUS for appendicitis,
has 84% sensitivity and 91% specificity, with higher
accuracy in children.

33. Abdominal Free Fluid Ultrasound
 Evaluating for free fluid is a common abdominal ultrasound application.
 Right Upper Quadrant (RUQ) – Morison’s Pouch.
 Left Upper Quadrant – Perisplenic Recess.
 Pelvis – Retrovesical Pouch

34. US has a sensitivity and specificity in the detection
of intraperitoneal free fluid of over 90%, while up to
10 mL of free fluid can be detected by POCUS.

35. Small Bowel Obstruction Ultrasound

36. Small Bowel Obstruction Ultrasound
 The ultrasound technique for detecting SBO is known as “mowing the lawn” .
Starting in the RLQ and using graded compression, slowly scan the abdominal
quadrants.

37.  1.Dilated bowel loops (diameter > 3cm).
 2.Ineffective or absent peristalsis, which will be seen
as a “whirling” of intra-luminal contents.
 3.Collapsed colonic lumen.
 When 2 of 3 of these findings are present, POCUS has
sensitivities and specificities of over 90% to detect SBO.
Small Bowel Obstruction Ultrasound

38. When bowel obstruction is suspected, POCUS has 90%
sensitivity and 96% specificity.

39. Pneumoperitoneum Ultrasound
 The most common finding for pneumoperitoneum is the Enhanced Peritoneal
Stripe Sign. This is when air within the peritoneal space rises and causes an
“echoing” of the usually single, hyperechoic peritoneal stripe that separates
the abdominal wall from underlying peritoneal fluid and fluid-filled organs.
 If there is a large amount of pneumoperitoneum, your image of abdominal
organs will be obscured by gas wherever you place your probe.

40. X ray had a sensitivity of 79%, specificity of 64% for
pneumoperitoneum. Ultrasound proved superior in terms of
sensitivity at 93% and at least specificity at 64%.

41. Reference
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 Point-of-care ultrasound on way to the right and rapid to the diagnosis.
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 Sonographic detection of pneumoperitoneum.