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.

Here are the chest ultrasound images from a cardiac surgery patient. They were obtained from the sternal area and represent comet tail artefacts from sternal wires. They look like B-lines but they are in the black background of sternal shadow rather than hazy background of the lung. Moreover, they are arranged in zig zag pattern unlike B-lines.

Note the chest X-ray from the same patient showing sternal wires.

In terms of mechanism, these are a form of reverberation artefacts where the echoes generated from the main beam are repeatedly reflected, in repeated trips before going back to the transducer. Remember, time = distance in ultrasound language and the machine places echoes making repeated trips one below the other (taking more time to reach the probe = placed below), finally creating a vertical line. On the other hand, lung B-lines are ring-down artefacts. Consider watching this video (20 min-27:30) if you need to review these and other important artefacts.

While scanning urinary bladder in women, we may occasionally encounter sonographic findings suggestive of pregnancy.  The earliest definitive evidence of pregnancy visible on ultrasonography (typically endovaginal) is the gestational sac appearing as a round, anechoic structure surrounded by thickened decidua without visible contents. At this stage, it might be difficult to distinguish true gestational sac from a pseudosac.

However, by the time it is detectable on transabdominal scans (6-7 weeks’ gestation; better seen when the urinary bladder is full), usually there are visible contents (yolk sac, fetal pole) inside the gestational sac. Visualization of a yolk sac is the first definitive evidence of an ‘intrauterine’ pregnancy. Ectopic pregnancies are rarely visible on transabdominal ultrasound but do watch for free fluid in the Morison’s pouch = could be sign of a ruptured ectopic that will likely require surgical intervention. Following are normal transabdominal images of an early intrauterine pregnancy.

Rarely, you may also find intact intrauterine contraceptive device (IUD) alongside the gestational sac (= contraception failure), which warrants immediate referral to the appropriate specialist. Following 2 cases illustrate this phenomenon.

These days, portable automated bladder scanners are widely used to check for urinary retention in hospitalized patients. They certainly avoid the need for invasive chatheterizations but cannot differentiate between urine and other fluid collections such as ascites. We recently published a case where bladder scanner falsely read ~800cc of urine but POCUS demonstrated that it actually was pelvic ascites in a patient with cirrhosis. In the transverse plane, uterus was seen floating in the pelvic ascites and together with ovarian ligaments, giving the appearance of a “TIE fighter”. Here is the video abstract:

The cervix is not well visualized on transabdominal scans in most patients. The endovaginal approach usually results in more optimal visualization because the transducer can be placed closer to the cervix and allows the use of high frequency probes. However, large tumors can be incidentally found while looking for urinary bladder in the suprapubic region. Here is one such case of a huge cervical carcinoma appearing as a heterogeneous irregular structure in the bladder area.  

In a female patient presenting with lower abdominal pain, abnormal ovarian (cyst) location, that is, in midline above the uterus and adjacent to urinary bladder on transabdominal scan suggests ovarian torsion. As both bladder and the cyst are anechoic structures, it appears as if there are two bladders next to each other. In addition, watch for free fluid in the pouch of Douglas.

Why talking about cyst? Note that torsion is usually associated with an ovarian cyst that twists along the infundibulopelvic ligament and pedicle, subsequently compressing the ovarian vein and artery leading to stromal edema and ovarian enlargement. Presence of the cyst is a clue to ovarian location as the ovarian tissue itself is not clearly visualized on abdominal scans. Following are 3 illustrative cases: