Interactive Transcript
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Our next patient is 36 years old and came to the ED
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3 00:00:03,440 --> 00:00:03,800
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with bleeding and pain.
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She gets her ultrasound again.
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We always start with a trans
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abdominal view right here.
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So you can see this is a bit of the uterus right here,
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and then we have all of this shadowing.
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And unlike some of the others we showed
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you earlier, this is dirty shadowing.
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It's not clean anechoic shadowing that you
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would expect to see with calcification.
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So we're suggesting that maybe there's
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going to be air in this particular location.
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And again, this is a transabdominal,
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so you always want to think, am
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I actually looking at bowel here?
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However, this did look like it's
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probably going to be uterus.
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Few more images here.
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Again, this is a very uterine type shape.
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This is the fundus right here, and lots of
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dirty shadowing coming centrally from within it.
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Imaging of the adnexa didn't really
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contribute in this particular case,
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but we do have an enlarged uterus.
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13.
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5 centimeters is bigger than expected.
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And then we skip to our transvaginal,
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where we see some free fluid in the pelvis.
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And again, cervix looks okay.
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Lower uterine segment starts to look okay, and
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then we see all these echogenic foci, and again
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with dirty shadowing posteriorly behind it.
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And it's going to obscure everything
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behind as well, so this is, of course,
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going to be a limited ultrasound.
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At this point, we'll skip
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to some of the cine clips.
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We'll show you here, this is the transabdominal
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sagittal view, and you can maybe see
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a little bit of endometrium out here.
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On the side.
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And as we get more centrally,
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echogenic foci, dirty shadowing,
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can't see much of anything behind it.
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Going back to transvaginal.
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Let's take another look at that.
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See if we can figure out a little
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bit more of what's going on here.
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So whenever you start to see
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gas in the endometrium, which I
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feel like we can confidently say
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that's where this gas is located.
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The first thing I tend to
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think of is endometritis.
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And when you're thinking endometritis, that
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is in a very specific clinical situation.
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So you're going to be recently
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postpartum or post a surgical procedure.
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And so you need to have that history
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in order to diagnose that via imaging.
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They also tend to be pretty toxic.
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They're going to be pretty sick, with high fevers,
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white count, just looking toxic in general.
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And so this patient wasn't in this case.
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So then we kind of had to think
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back and see what's going on here.
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What could this possibly be?
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And I think looking at this
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transverse uterus, syn a clip.
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This is the one that helped us figure
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out the best what's going on here.
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So again, with all the air, it's very easy
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to just get distracted and only think of
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that air and just think, endometritis.
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Endometritis.
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Endometritis.
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I need to call somebody.
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This is important.
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This patient is really sick.
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There's a lot of gas.
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And here I would argue yes,
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that's what I'm still thinking.
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But if you look closer at this and kind of
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take a step back, take your pulse, breathe,
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and you come to the fundal portion of it.
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This is an antidependent air right here.
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It's kind of centrally within the
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canal, and there's just more structure
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going on anteriorly up here.
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We'll go back to that sagittal image right here.
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Air here is very antidependent; air wants to
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float, basically, but over here it's not.
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And that doesn't make sense because if this
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is endometritis, air in the endometrium,
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it should fill the entire cavity, the
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most antidependent portions, and it's not.
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So when you have a case like this, you need
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to again, step back and think about it.
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What else could this be?
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This person wasn't toxic.
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They weren't sick.
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They didn't have a fever or a high white count.
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They were just bleeding and in pain.
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And so it turns out she did
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have a history of a fibroid.
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And so when fibroids get necrotic,
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they can have gas internally.
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It does not mean that they're infected.
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In fact, it's very unusual for them to get
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infected, but when they become necrotic,
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they can have gas internally within them.
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And so this was most likely going
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to be an intracavitary fibroid that
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was necrotizing and had air within it.
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We don't have follow-up at
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our system to prove this.
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She did not end up getting a CT scan, which
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would have been really neat to correlate
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with, but she did go to surgery shortly
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after, which proved that this was a necrotic
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intracavitary fibroid that was causing this.
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So again, endometritis is your first
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thought for this, but if it doesn't fit the
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clinical picture, step back, think about a
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necrotic fibroid as an alternative etiology.
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