Author Archives for Abhilash Koratala

About Abhilash Koratala

I am a board certified Nephrologist and specialist in clinical hypertension. I am a clinician educator interested in point of care ultrasonography (POCUS). I have designed and developed a successful point of care renal ultrasonography curriculum for Nephrology Fellows. This blog is primarily to gather all the POCUS images I posted on Twitter (@NephroP) and to share interesting stories and articles related to POCUS.

An unusual case of ascites

Here is an interesting case shared by Pitt IMPOCUS. A middle-aged man with cirrhosis and history of venous thromboembolism on apixaban therapy presented with abdominal pain and distension. On examination, there was bilateral pitting pedal edema, distended abdomen with tenderness but no clinical signs of peritonitis. Laboratory data was significant for a serum creatinine of 2.2 mg/dL and a hemoglobin of 7.4 g/dL. No recent baseline available. POCUS demonstrated the following:

At first glance, it looks like there is ascites on this right upper quadrant image along with a simple renal cyst in the upper pole. Otherwise, nothing concerning. There was no evidence of pneumoperitoneum either (image not shown). More images shown below:

Now, it looks like the ascites is complex with internal echogenicities suggestive of an exudative origin. So, the likely diagnosis is spontaneous bacterial peritonitis?

Oh wait, what is this thing on top of the liver? Doesn’t seem to be a part of the liver. That in fact is clotted blood!! & the echogenicities are fibrin strands. So, the diagnosis is spontaneous hemoperitoneum in the setting of liver disease and oral anticoagulation therapy. Following image (oblique plane) demonstrates the ‘hematocrit sign’, which essentially means layering effect noted within large collections of extravascular blood when the collection separates into two gravity dependent layers with differing echogenicities.

Take-home point: Always consider the possibility of hemoperitoneum in a case of complex ascites, especially if there are risk factors for bleeding and/or there is drop on hematocrit. May also be seen after traumatic paracentesis. Compare this case to the previously discussed hemothorax.

Complex pleural effusion

As we saw before, a simple transudative pleural effusion is anechoic. On the other hand, presence of echogenicities in the effusion is suggestive of complex/exudative pleural effusion. The term ‘plankton sign’ is often used to indicate debris appearing as swirling, punctiform echoes in such effusions and may indicate infection or hemothorax depending on the clinical context. Rarely, it can be seen in simple effusions after aggressive diuretic therapy. As the collection progresses, fibrin is activated and septations or loculations appearing as thin hyperechoic lines begin to form within the fluid collection, resembling a ‘spider web’. This is an important finding because effusions with septae are more likely to require a surgical intervention rather than a chest tube drainage and antibiotics alone.

Following are several examples of complex pleural effusion/empyema.

Not every spine sign is from pleural effusion

We have previously discussed the utility of ‘spine sign’ in diagnosing pleural effusion on POCUS. One of the short videos also talks about this. However, it is important to note that this sign is not specific to effusion. Anything that provides a medium for the ultrasound beam to pass through in the lower chest allowing visualization of vertebral bodies above the diaphragm gives spine sign. For example, lobar consolidation, pulmonary contusion or a mass can do this. Below is an illustrative image shared by Dr. Robert Jones. There is trace pleural effusion, but the spine sign is mainly coming from consolidation in this case.

Massive lymphocele associated with renal allograft hydronephrosis

Approximately 3 weeks after deceased donor kidney transplantation, a patient developed oliguric renal failure. Renal sonogram demonstrated moderate hydronephrosis of the renal allograft secondary to compression of the transplanted ureter by a large fluid collection in the pelvis (Figure 1, top panel). CT scan confirmed the same (Figure 2) and the patient underwent ultrasound-guided drainage of ~450 cc fluid the next day with drain placement leading to improvement in urine output. Laboratory analysis of the fluid was consistent with lymphocele and repeat sonogram showed significant improvement (Figure 1, bottom panel).

Lymphocele is a lymphocyte-rich fluid collection that results from disruption of lymphatics in the recipient during renal transplantation. While small collections resolve spontaneously, larger, symptomatic ones may cause obstructive nephropathy requiring percutaneous or laparoscopic drainage. Prompt diagnosis obviates the need for renal replacement therapy.

Not a routine pleural effusion

This is an image obtained from the perisplenic window in a patient with gun shot wound. At first glance, it looks like a regular pleural effusion with atelectatic lung above the spleen. If you take a closer look, a huge mass of jelly-like clotted blood can be seen in between the spleen and collapsed lung surrounded by anechoic fluid, which is most likely unclotted blood (i.e., hemothorax) in this clinical context. Sonographic image courtesy: Dr. Robert Jones.

More relevant scenario for internal medicine folks would be a patient with hypercoagulable state undergoes thoracentesis and follow up chest ultrasound demonstrates this finding. Though this degree of bleeding is uncommon, fibrin stranding is often seen in such cases, which can be confused with pleural effusion of infectious origin. Interpretation of POCUS findings in the right clinical context is the key.

Similar to the above case but a different scenario, here is an interesting image shared by Dr. Hailey Hobbs. What looks like liver initially is actually a well-circumscribed empyema!! Note the heterogeneous echotexture and moving particles in that structure. Take home message: Always slide through the area of interest instead of a ‘single point’ examination.

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