0:01

Our next patient is 36 years old and came to the ED

0:02

3 00:00:03,440 --> 00:00:03,800

0:03

with bleeding and pain.

0:06

She gets her ultrasound again.

0:07

We always start with a trans

0:08

abdominal view right here.

0:10

So you can see this is a bit of the uterus right here,

0:11

and then we have all of this shadowing.

0:14

And unlike some of the others we showed

0:15

you earlier, this is dirty shadowing.

0:17

It's not clean anechoic shadowing that you

0:19

would expect to see with calcification.

0:21

So we're suggesting that maybe there's

0:22

going to be air in this particular location.

0:25

And again, this is a transabdominal,

0:26

so you always want to think, am

0:27

I actually looking at bowel here?

0:29

However, this did look like it's

0:30

probably going to be uterus.

0:32

Few more images here.

0:33

Again, this is a very uterine type shape.

0:36

This is the fundus right here, and lots of

0:37

dirty shadowing coming centrally from within it.

0:41

Imaging of the adnexa didn't really

0:43

contribute in this particular case,

0:44

but we do have an enlarged uterus.

0:46

13.

0:47

5 centimeters is bigger than expected.

0:51

And then we skip to our transvaginal,

0:52

where we see some free fluid in the pelvis.

0:54

And again, cervix looks okay.

0:56

Lower uterine segment starts to look okay, and

0:58

then we see all these echogenic foci, and again

1:01

with dirty shadowing posteriorly behind it.

1:06

And it's going to obscure everything

1:07

behind as well, so this is, of course,

1:09

going to be a limited ultrasound.

1:11

At this point, we'll skip

1:12

to some of the cine clips.

1:14

We'll show you here, this is the transabdominal

1:17

sagittal view, and you can maybe see

1:18

a little bit of endometrium out here.

1:20

On the side.

1:22

And as we get more centrally,

1:23

echogenic foci, dirty shadowing,

1:26

can't see much of anything behind it.

1:32

Going back to transvaginal.

1:34

Let's take another look at that.

1:35

See if we can figure out a little

1:36

bit more of what's going on here.

1:40

So whenever you start to see

1:40

gas in the endometrium, which I

1:42

feel like we can confidently say

1:44

that's where this gas is located.

1:46

The first thing I tend to

1:47

think of is endometritis.

1:49

And when you're thinking endometritis, that

1:51

is in a very specific clinical situation.

1:53

So you're going to be recently

1:54

postpartum or post a surgical procedure.

1:58

And so you need to have that history

1:59

in order to diagnose that via imaging.

2:03

They also tend to be pretty toxic.

2:05

They're going to be pretty sick, with high fevers,

2:07

white count, just looking toxic in general.

2:10

And so this patient wasn't in this case.

2:13

So then we kind of had to think

2:14

back and see what's going on here.

2:15

What could this possibly be?

2:17

And I think looking at this

2:18

transverse uterus, syn a clip.

2:21

This is the one that helped us figure

2:22

out the best what's going on here.

2:24

So again, with all the air, it's very easy

2:26

to just get distracted and only think of

2:28

that air and just think, endometritis.

2:29

Endometritis.

2:30

Endometritis.

2:30

I need to call somebody.

2:31

This is important.

2:32

This patient is really sick.

2:33

There's a lot of gas.

2:35

And here I would argue yes,

2:36

that's what I'm still thinking.

2:37

But if you look closer at this and kind of

2:39

take a step back, take your pulse, breathe,

2:42

and you come to the fundal portion of it.

2:45

This is an antidependent air right here.

2:48

It's kind of centrally within the

2:49

canal, and there's just more structure

2:51

going on anteriorly up here.

2:54

We'll go back to that sagittal image right here.

2:56

Air here is very antidependent; air wants to

2:59

float, basically, but over here it's not.

3:02

And that doesn't make sense because if this

3:04

is endometritis, air in the endometrium,

3:05

it should fill the entire cavity, the

3:07

most antidependent portions, and it's not.

3:09

So when you have a case like this, you need

3:11

to again, step back and think about it.

3:14

What else could this be?

3:15

This person wasn't toxic.

3:16

They weren't sick.

3:17

They didn't have a fever or a high white count.

3:19

They were just bleeding and in pain.

3:21

And so it turns out she did

3:22

have a history of a fibroid.

3:25

And so when fibroids get necrotic,

3:27

they can have gas internally.

3:28

It does not mean that they're infected.

3:30

In fact, it's very unusual for them to get

3:32

infected, but when they become necrotic,

3:34

they can have gas internally within them.

3:36

And so this was most likely going

3:38

to be an intracavitary fibroid that

3:41

was necrotizing and had air within it.

3:43

We don't have follow-up at

3:44

our system to prove this.

3:45

She did not end up getting a CT scan, which

3:47

would have been really neat to correlate

3:49

with, but she did go to surgery shortly

3:51

after, which proved that this was a necrotic

3:54

intracavitary fibroid that was causing this.

3:56

So again, endometritis is your first

3:59

thought for this, but if it doesn't fit the

4:00

clinical picture, step back, think about a

4:03

necrotic fibroid as an alternative etiology.