Anatomy appears strange remember that air filled

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Anatomy appears strange? ± Remember that air-filled bowel is going to make it very difficult for the ultrasound to generate much of an image, and largely white shadows will be seen. Gentle consistent pressure or changing the patient’s pos- itioning can sometimes help to get you a better window. Not sure what you are looking at? ± Always use color Doppler to help distinguish fluid collections from vessels. Diagnostic ultrasound 235 Gastrointestinal ultrasound
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Normal images Figures 12.9 and 12.10 demonstrate normal bowel anatomy. Abnormal images Figures 12.11 –12.15 demonstrate abnormal bowel and abdominal wall anatomy. Figure 12.9 Normal bowel. Figure 12.10 Intact peritoneum (*). 236 Diagnostic ultrasound Gastrointestinal ultrasound
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Figure 12.11 Appendicitis: long-axis view with diameter of 1.3 cm. Figure 12.12 Small bowel obstruction with extraluminal free fluid (F) and dilated bowel loops (B). Figure 12.13 Abdominal wall hernia sac (HS). Diagnostic ultrasound 237 Gastrointestinal ultrasound
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Literature review Figure 12.14 Appendicitis with appendicolith (A) and edematous bowel wall. Figure 12.15 Hernia. HS, hernia sac; PD, peritoneal defect. Reference Methods Results Notes Ramarajan et al. 2009 [ 4 ] 680 patients with suspected appendicitis followed pathway of US followed by CT if ultrasound was equivocal. Outcomes were 407/680 patients followed pathway. 200/407 were managed without CT. Sensitivity was 99% and specificity 91% for pathway of US as screening test. Outcome study looking at US as first-line test in suspected appendicitis. Retrospective, and unclear if CT use was reduced 238 Diagnostic ultrasound Gastrointestinal ultrasound
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New directions Again, one of the major forces that will determine how patients are worked up diagnostically in the decades to come will likely be cost and a more conscientious approach to radiation exposure. Gastrointestinal complaints are most assuredly worked up more completely and with more accuracy by CT scanning. However, outcomes-based research looking at comparative effectiveness when clinicians use point-of-care ultrasound to screen for dis- ease states may show not only that ultrasound can obviate some CT scans but perhaps that it can even be used to more closely monitor patients and replace many of the plain abdominal x-rays that are performed today. References 1. Sivit CJ, Newman KD, Boenning DA, et al. Appendicitis: usefulness of US in diagnosis in a pediatric population. Radiology 1992; 185 : 549–52. 2. Anderson SW, Soto JA, Lucey BC, et al. Abdominal 64-MDCT for sus- pected appendicitis: the use of oral and IV contrast versus IV contrast material only. AJR Am J Roentgenol 2009; 193 : 1282–8. 3. Wong KK, Cheung TW, Tam PK. Diagnosing acute appendicitis: are we overusing radiologic investigations? J Pediatr Surg 2008; 43 : 2239–41. 4. Ramarajan N, Krishnamoorthi R, Barth R, et al. An interdisciplinary initiative to reduce radiation exposure: evaluation of appendicitis in Reference Methods Results Notes correlated with US and CT findings.
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