Computed Tomography Diagnosis of Appendicitis
The CT abdomen/pelvis with IV contrast shows a dilated appendix (see red outline) with thickened, hyperenhancing wall (see blue outline) best visualized in the axial and coronal planes.
Abdominal/Gastroenterology
Gastric Bezoar
In the abdominal radiograph, a nonspecific and non-obstructive bowel gas pattern with no air-fluid level was noted, however the stomach was distended with soft tissue. The CT abdomen/pelvis revealed a distended stomach with undigested heterogeneous contents (presumed bezoar).
Cholelithiasis: WES Sign
Abdominal ultrasound showed the classic presentation of the Wall-Echo-Shadow (WES) sign. The superficial aspect of the gallbladder wall is represented by a hyperechogenic curve. Below this, bile fluid is represented by hypoechogenicity. Underneath the bile fluid is the echo of the dense border created by the collection of gallstones, represented by a hyperechogenic curve. Due to the high density of the gallstones, nothing deeper can be visualized (including other gallstones or the far end of the gallbladder); this is the shadow.
Perforated Duodenal Ulcer
In the chest radiograph, there was obvious free air under the both the right diaphragm (above the liver) and the left diaphragm, consistent with pneumoperitoneum.
Abdominal/Gastroenterology, Simulation
Mesenteric Ischemia
At the end of this simulation session, the learner will: 1) Recognize signs and symptoms of mesenteric ischemia; 2) order appropriately imaging and labs in the workup of an elderly patient with abdominal pain; 3) manage a patient with mesenteric ischemia, a rare, but serious cause of abdominal pain in the elderly; 4) discuss anchoring bias, specifically related to patients referred to the ED with an established diagnosis by outside specialists.