Lessons From CQI Cases - Pelvis - SD

Introduction

Good morning, good afternoon,
or good evening, whatever the time is with you.
I'm Dr. John McGann.
I'm a professor of radiology at the University
of California Davis Medical Center,
located in Sacramento, California.
I'm also the director of abdominal imaging and ultrasound.
As such, I also overlook CQI
or continuous quality improvement for our section
in particular, ultrasound.

The talk I'm gonna give you today is on CQI in the pelvis.
I'm gonna use different examples to show
how you may improve quality within your institution
by learning from mistakes
as we've learned from some of our mistakes.

Lessons Learned from CQI Cases

Hello, we're gonna talk about lessons learned
from CQI cases.
CQI refers to continuous quality improvement.
You can see from this case done at AM
This is a renal biopsy.
I'm gonna use this case to show you
how we can improve quality.

What is Continuous Quality Improvement?

What is continuous quality improvement?
How does it work? How do we learn from our mistakes
and how can we improve through learning such
as continuous medical education?

Let's go back to the case that I showed you.
All of a sudden we've turned on color doppler here.
Three minutes later we see we have a large
A VM or a large color line coming
around the perinephric space
and it certainly appears worrisome to us.
A few minutes later, by 9 43 we look at this color line.
This color line has decreased in that time period since then
and by 9 45
or AM this line has
completely disappeared.

How can we use this to improve quality improvement?
If we look at this, this has
been published in the literature.
It's been called the patent track Sign.
This was published originally by Kim
and the American Journal of Radiology.
In 2007, they identified this line
or this patent track line 12% of all their liver biopsies
and for their biopsies it persisted more than five minutes.
All four. These had significant bleeding.
In fact, if we see this color line, we can then go ahead
and predict which patients may have significant bleeding.

Similar results were published in the Journal of Ultrasound
and Medicine in the same year with renal biopsies.
Of those using a 14 gauge needle,
22% had vascular
abnormalities using color flow post biopsy.
Of those two of the original patients
had persistence of this color line more than 24 hours.
These had no big bleeding size,
but they did have AVMs or avs.

We did a recent study that is impressed in the Journal
of Ultrasound and Medicine, looking at 104
radio frequency ablations of either the kidney or the liver.
Five of these had the color line sign.
This incidence is much less than that
of other biopsy studies where they had 22% or 12%.
This is probably due to the fact that
as we pull out our needle, we coagulate the track
or burn the track to help prevent bleeding.

Proactive Methods from the Auto Industry

Basically we can look back
to the auto industry has taken a proactive method
to prevent adverse outcome.
For instance, their scheduled maintenance, that's to help
with adverse outcome or airbags.
And airbags are certainly nothing new.
They were available in the 1980s, not used
because of the cost benefit, but now they're used.
But this is a proactive method that the auto industry took
to help alleviate deaths with auto accidents.

We can do the same thing through education.
Before we step in
and we do something, we can educate ourselves
and decide, maybe this is not what we should do
or maybe this is what we should do.
And that's why continuous quality improvement,
helps improve our outcome.
And that's why education or CME meetings are also helpful.
We can be proactive.
We can introduce the color line sign into our practice.
Anytime we go ahead and we do a biopsy
or we do a radio frequency ablation
or we introduce a needle anywhere, we can go ahead use
that color line sign to help identify color
or doppler arterial venous waveform.

That will then alert the examiner, alert us
to the possibility that
that patient may have active bleeding or hemorrhage
or other complications related to that.

Clinical Example: Radiofrequency Ablation in a Jehovah's Witness Patient

Let's see how that could work in practice.
This is a 63-year-old male who had hepatitis C.
I did A RFA for a hepatoma.
This individual in 2003, which was quite successful,
repeated this in 2005.
Then in 2007 came forward with two new hepatoma.
This illustration demonstrates the region of RFA,
which is echogenic and I'm pulling the needle out.
Now all the sudden,
very subtly we see this color line sign
just in the subcapsular region of the liver
where the needle electrode had been removed.
This persisted for a few minutes.
Here we can see a minute or two later
and then we note it persisted for over 15 minutes.

We can see this color line sign
and perhaps there's a small subcapsular hematoma.
That is only half of the story.
This patient was a Jehovah's Witness,
refused all blood products, had normal platelets
but increased INR.
I knew that going into that.
And then I used the color line sign.
I saw that I had an arterial wave form here.
When I see this arterial wave form that persisted
for 15 minutes, that was certainly worrisome.
I asked his wife would he accept any fresh frozen plasma
or any blood products They refused.
But what we had done before, we went ahead and did his RFA.
We had consented him
for possible embolization if we had any problems
because we knew he had elevation
of his clotting parameters in such a way
that we can see pre embolization,
this little arterial fleet feeder with an area
of active extravasation.
These are a post embolization images.
This basically shows us how introduction
of a new technique such as just a simple technique
of putting color flow after a biopsies or
after radiofrequency ablation,
can help manage potential complications.

And the real question is wonder if we have not used color
flow in this case and we have not detected this active
bleeding or we have performed the procedure under CT
and we have not known this,
we could had potential catastrophic
effects a few hours later.

Also, there are lessons learned even from our mistakes,
and this is really as some people would say, a opportunity
for improvement.
I'm gonna give you three cases here.
All are basically the same
or we're gonna look at three separate outcomes here.
These are all gonna be patients with positive beta HCG
and vaginal bleeding.

Case 1: Positive Beta HCG and Vaginal Bleeding

Case number one.
This was interpreted as gestational sac here.
They came up with a mean sac diameter of 23 millimeters
with a gestational age of six weeks, six days.
If we look at realtime image, you can see the realtime image
of what was interpreted as the gestational sac in this case.

I'll give you a laundry list here.
What do you think it is? Do you think It basically is a
normal IUP and abnormal IUP or an ectopic pregnancy
or a couple of these others that I've listed up here?

We look back at those numbers
and in general you can't use these as an all or none,
but these are not bad rules.
Usually about eight millimeters mean sac diameter.
We should fairly reliably identify a yolk sac
and by 16 millimeters mean sac diameter fairly reliably
identify a embryo.
Basically if we have a mean sac diameter of 23,
we're probably dealing with either an abnormal IUP
or an ectopic pregnancy.

Let's see what this case was.
Basically this was called fetal demise with retain products
of conception.
If we look at this very carefully, we actually see this
and then we see another cystic structure.
This cystic structure looks like it may in fact have a
double deci reaction.
We have actually two.
This was called originally the gestational sac.
Remain calm in these situations.
Don't jump to any conclusions 'cause we're gonna go
and see what was done in this case.

The real key
to this case was in fact they did a followup
scan in five days.
And in five days this structure is seen over here was in
fact the smaller structure was seen as a gestational sac.
By that time there was a yolk sac
and this was a subc chorionic bleed
that was not the gestational sac.

What do we know about prognosis?
Basically the larger size, the earlier in pregnancy
and the more advanced maternal age, the worst,
the prognosis in this case there is three strikes
and yet I show you a scan at 20 weeks follow up
and there was at that time a normal pregnancy.

Case 2: Positive Beta HCG and Vaginal Bleeding

Second and third case, again very similar situations,
positive A-D-A-C-G and vaginal bleeding.
Case number two 34-year-old female
positive beta HCG.
And you can see right here we get a gestational sac,
mean sac diameter of about 12
and it was called very early gestational sac
but no ylk sac was identified.
I'm gonna show you this over here.
This is part of the right ad nexa.
We have this as a gestational sac. This is the right ad.
Nexa mean sac diameter of 12.5.

When we have a mesac diameter 12.5, we would expect
to identify probably a yolk sap, perhaps a fetal pole,
not certainly all the time.
We're probably de dealing with either an abnormal IUP
and an ectopic pregnancy.
You have your laundry list down here again.
Normal abnormal IUP
or an ectopic pregnancy in this case.

Again, what should this measurement be?
12 point Uh five. What, what should we see?
Should we see a very early gestational sac
without a yolk sac?
Yes or no? Again, we come back to our measurements of eight
and 16 Mean sac diameter was greater than 12 should,
we should probably expect to see a yolk sac.

Here's what was said.
Could not exclude a blighted oum or an ectopic.
They did pretty good.
Is there anything else we should do at this time?
This came in on a Friday afternoon as an outpatient.
What else should be done?
A call to the clinician would be very, very helpful.
No call was made.
It ended up this individual,
we can see here another ring here that wasn't recognized.
This was an ectopic pregnancy.
She ended up going to another ER with vaginal bleeding,
had a right cell pingle ectomy for an ectopic pregnancy.

I think the lesson learned here is
to always call back in these cases where we find something
that may be potentially treatable.
Again, looking at this pseudo gestational
sac was identified.
These are findings described over 20 years ago
and a non-specific adexo mass occurring in 28%
of cases of ectopic pregnancy
in this series done over 20 years ago.

Case 3: Positive Beta HCG and Vaginal Bleeding

Final case, again, positive pregnancy test
and some spotting.
We look here, this is not the mean sac,
but this is a gestational sac measurement.
It would be about five or six millimeters
and this was seen in the right adex.
Exhale. Again, we're gonna come down normal IUP,
abnormal IUP
or an ectopic pregnancy are the most common things here.

Again, we come back mean sac diameter at six or five.
Should we see a yolk sack?
Not necessarily should we see an embryo probably vary
unlikely in this case.
I think you have to use caution,
keep all options on the table at that time.
The pendulum is sort
of towards everybody worrying about ectopic pregnancy.
We have to exclude a topic, rule out a topic, et cetera.
But remember there may be still there a normal IUP.

In this case it was called an ectopic pregnancy.
Over here ring a fire.
And over here this was called a pseudo gestational sac.
Methotrexate was administered
but there is persistent bleeding or spotting in this case.
They went ahead, they did a right cell pingle ectomy
removed a normal right ovary was a cyst
and a normal tube.
But what was worse in this case, three days later we see
what we identify as we think is a small yolk sack.
And 16 days later that pregnancy is not progressed.
She lost both her ovary tube and her pregnancy.

Remember to carefully consider all possibilities in these
cases with a positive pregnancy test and no definitive IUP.
You may be in fact just too early
or you could have an ectopic pregnancy,
but don't be
so definitive in calling an ectopic pregnancy when you're
very, very early in these cases.

Second Trimester Pregnancy Cases

Scan number four and five both performed in the second
trimester pregnancy
and a mass routine scan at 20 weeks.
Here's our pregnancy
and then here's the lower uterine segment
or the lower portion the bladder is seen right here.

The question, what is occurring here? What is this mass?
Is that a previa accreta fibroid,
myometrial contraction, an ectopic pregnancy?
What are we talking about?
You come up with your best answer here.

Call normal IUP with a fibroid over the oz.
But if you look carefully at this, this isn't a fibroid.
That's the normal uterus.
In fact what this was was an abdominal pregnancy.
This is the normal uterus lesson learned.
Look for the uterus very carefully.
This is an en large uterus.
Abdominal pregnancy has lack of myometrium
or a very thin line as all we see,
which isn't myometrium surrounding the pregnancy.
Often oligo hydrous,
not in this case maybe in direct contact
with the an abdominal wall.

Can these go on to live births these abdominal pregnancies?
The answer is yes.
And out of Africa there's been a number of series.
These were 19 cases that they had
two resulted in live births.
The mothers, really had no prenatal care
and at laparotomy they found a 38 week
and 39 week gestation with weights of,
twenty four hundred and twenty five hundred grams.

Unusual Ectopic Pregnancies: Interstitial and Cervical

Unusual ectopics to look for are interstitial ectopics,
also called cornew, but that's probably incorrect.
They're actually interstitial.
This is a very unusual case of an interstitial ectopic.
You can see over here something over the region
of the s called potentially a fibroid down here.
But you look over here in one side, very, very, very thin
what was interpreted as myometrium, which probably is,
but these are centimeter markers.
Whatever that is is probably only three millimeters thick
called normal IUP at 20 weeks with complete placenta previa
and large fibroid.

But look what happened. 23 weeks acute pain.
This is now the pregnancy.
Here you see a femur
but you see no amniotic fluid at all.
You see fluid within the abdomen at this time.
Free fluid up here.
And what was called, it was called interval development
of oligo hydrus acutely at 24 weeks.
Free fluid in the abdomen, please check liver function test.
This was an interstitial ectopic pregnancy.
And I think when you see something go from this to this
and there's spontaneous free fluid, it is a very,
very worrisome sign.

Make sure you exclude a cornew, which is a bi part
of a bico pregnancy in which there's a pregnancy in one
of the horns or a fibroid plus pregnancy may be very
difficult in some cases.
Part of this there you'll see a very thin line in a
myometrium surrounding the pregnancy,
which is eccentrically located within the uterus.
Or you may see this interstitial line sign in which part
of the endometrium comes out here to meet this,
eccentrically located pregnancy here in an
interstitial ectopic.

Finally unusual ectopics include cervical ectopics.
Their frequency is certainly increasing now probably due
to C-sections.
You can see this from the article, A journal
of Australian Asian Journal of ultrasound.
And you can see all these c-section scars.
Some fill up with fluids, some do not.
But you can see here in this case,
just imagine ectopic pregnancy occurring here
or a normal intrauterine pregnancy
and part of the placenta coming down here,
what the potential problem that would be
because then you would have placenta accreta.

The instance of placenta, accreta, accreta
and perreta is certainly increasing with the use
of C-sections in the United States.

Now I'm gonna show you this case, which was a,
cervical ectopic pregnancy in a C-section scar.
This is the original realtime image
and this is a few days later.
And by that time you can identify the yolk sac
as you see right here in this c-section, scar.
And as we go on, we can treat this either
by ultrasound guided aspiration
or administering methotrexate.
In this case, you can see first on the upper left the,
again the cervical ectopic again our needle going in placed
endo vaginally.
And then as we go on again we see the needle being placed
into the yolk sac
and the amniotic cavity aspirated
until everything is completely gone.

Case 6: 16 Weeks Pregnancy with Abdominal Pain and Heterotopic Pregnancy

Over in, this final image,
this is a very unusual case.
This is case number six 16 weeks with a pregnancy
and abdominal pain.
And again, this pregnancy did have free
fluid in the abdomen.
Pregnancy seen up here, free fluid in the abdomen
and something over here in the adex cell.
What is this again? Differential?
Is this a rupture corpus luteal cyst, ovarian torsion,
heterotopic ectopic ovarian malignancy in a pregnancy.
You can guess which of these potentials it is.

We can see here again the 16 week pregnancy
and this mass.
And this was called torsion
or detorsion of a corpus luteal cyst.
In fact, there was robust color flow around here
and you can see right here the robust
color flow around there.
And this was in fact a ruptured heterotopic pregnancy over
in the left Aden Nexa.
And again, lesson learned spontaneous free fluid
as a very worrisome in pregnancy.

Heterotopic pregnancies can occur in various combination.
It was reported the rate was one in 30,000, maybe
much less than that is reported as high as 1% in IBF
for assisted reproduction.

Here's a case of A IUP
and a cervical ectopic pregnancy case six
and seven, history of abnormal uterine bleeding.

Cases of Abnormal Uterine Bleeding

Case 6: Heavy Bleeding with History of Fibroids

First case presents with heavy bleeding history
of fibroids and this was the initial ultrasound exam.

Case 7: Pelvic Fullness and Uterine Bleeding

Second case again, sort of a pelvic fullness,
uterine bleeding,
report could not be located at the endometrial biopsy.
And this was the ultrasound again, exam,
transabdominal endovascular scans.

What was this first case? Is it normal?
Normal fibroid endometrial cancer,
adenomyosis in the second case, what was it?
Was it normal fibroid, et cetera, et cetera.
All these different possibilities.

Let's look at the first case.
It was called a diffuse fibroid.
And this was not that long ago.
It was called a diffuse fibroid.
But even that went on from there.
Consultation was obtained from interventional radiology.
The consultation said uterine fibroids documented
mainly by ultrasound.
That individual did not check the ultrasound exam.
After that embolization,
the uterine artery ruptured six weeks post embolizations
patient's bleeding had increased follow up ultrasound came
up and at that time no specific fibroids identify.

There's a lots of lessons learned here.
First, don't over call just so you won't miss something
'cause there can be consequences of overcall.
If you call a ovarian cyst
and repeat it, in six weeks, it's only 1.5 centimeters.
It look simple. Really don't need to do that.
Or in this case, don't over call a fibroid just
because you don't want to miss something.
When we do interventional procedures,
certainly we must personally check all the studies
and all always consider a differential diagnosis here such
as adenomyosis in this case.

The other case that I showed you, the 49-year-old
with endometrial biopsy, this was thought
to be the endometrial stripe.
We looked at this endometrial stripe is now well seen in
large fibroid uterus
and they wanted to make the endometrial stripe there.
But what this ended up to turn out to be,
there was a mass there
and I think you can see it no color flow.
This turned out to be an endometrial stromal sarcoma.
Again, don't try to make things normal such
as the endometrial stripe.
Step back, take another look
and always consider a differential diagnosis.

Cases Distinguishing Fibroids from Sarcomas

Cases 8 and 9

Case eight and nine.
You can sort of see case eight, case nine.
This could be by ultrasound, but I have this by ct.
Same similar thing by ultrasound fibroid,
fibroid fibroid sarcoma, sarcoma.
Which one is normal?
Are they, or which one is a malignancy?
Which one is a fibroid?
Are they both fibroids, both sarcomas?
You make the call here
and sometimes no matter what we do, we just can't win.
And this is probably what's gonna happen
to you in this case, most people call this the sarcoma.
This was a giant limy.
This case the smaller of the two was a high grade sarcoma.

The sarcoma versus vibrate virtually impossible
to tell rapidly enlarge mass in a older female,
it's reported to be rare.
One in a thousand hysterectomies.
I don't believe that 'cause the number
of cases I've seen is much greater than that enhancing mass.
Look for other things.
Look at the kidneys, look at the livers.
If you have a very, very large what is called a fibroid
or uterine mass in a older woman

Cases with Solid Ovarian Masses and History of Fibroids

Case 10

Case 10 and 11, history of fibroids
with a solid ovarian mass.
This is a case 10.
Here's the uterus may maybe fluid in between here.
Here's the mass on ultrasound uterus, the mass,
they did color flow, not a lot of color flow there.
What is that?
Is that a the coma on ovarian mass
of pedunculated fibroid uterus, sarcoma,
et cetera, et cetera?

What this was called was ovarian mass on CT
'cause it looks like it was separate.
But question fibroid, a pula fibroid
on ultrasound without color flow.
What it was was an ovarian fibroma with torsion.
Remember then in a patient with pain
and ovarian mass, we couldn't tell.
Most ovarian masses are cystic
but they're more susceptible to ovarian torsion.
This is a very unusual case.

Case 11

The next case is very unusual as well.
Again, history of fibroids in this female, a large fibroid
18 centimeters on physical exam scans of the uterus.
Then over in the left a nexa.
This was the left ovary, four five centimeters solid mass
and a female over 50 years of age.
Post-menopausal other ovary was very small.
What was this over in the left ad nexa
again, you have your list here
as an ovarian tumor, et cetera, et cetera.
And what we see here is the uterus.
We see this mass and we did a follow-up ct.
This turned out to be a sarcoma with ovarian mets,
which were here, but mets throughout the chest
and the abdomen.

Conclusion: Implementing Continuous Quality Improvement

What is continuous quality improvement?
It's really how we can improve our quality
and we can improve it by continuous medical education,
by reading, introducing new things into our practice, such
as color flow after every biopsy or procedure that we do.
Or we can go back and look at our errors
and say, really, is there a systematic error
that we have when we're reading out?
If there is, how can we improvement?
Because everybody makes errors in terms of,
ultrasound,
looking at the pelvis.
The real thing is we have to look at this
as a potential opportunity for learning in these cases.

Thank you very much and I hope you learned a few things from
this, 30 or 40 minute presentation.