As ultrasound (US) is simple and less invasive, it is widely used for mass screening. However, it can be difficult to visualize the entire pancreatobiliary system due to complicated anatomy, obesity, and overlying gas. The left lateral decubitus position is suitable for visualizing the biliary tract system. Both high-resolution US and magnified images are essential. As for the gallbladder, management of artifacts including reverberation and side lobes is a key issue. To trace the total course of the extrahepatic bile duct (EHBD), the probe should be moved as if we are writing an inverse letter C. As the position of the pancreas changes inside the body depending on the posture, we should employ both lateral decubitus positions to delineate the pancreatic head and tail without compressing strongly with the probe. As lesions in the groove area and the ventral pancreas tend to affect neither the EHBD nor the main pancreatic duct (MPD), we should pay attention to those areas. We should also highlight the dilated MPD and pancreatic cysts as important US findings for individuals at high risk for pancreatic carcinoma, and adopt several postural changes and the liquid-filled stomach method to visualize the pancreas with as wide a range as possible.

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Congenital heart disease is a common disorder. Ventricular septal defect and atrial septal defect are the most common pathology, comprising approximately 40% of cases of congenital heart disease. As in most types of congenital heart disease, echocardiography has become the keystone for precise diagnosis and determination of the direction of clinical care and approach to therapeutic intervention in these disorders. Thus, although the presence of ventricular septal defect or atrial septal defect is often easily detected, ideal echocardiographic evaluation and interpretation require that one has a detailed understanding of septal anatomy, the relationships of defects to other cardiovascular structures, and the impact of these defects on hemodynamics.

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Purpose: To evaluate the efficacy of cross-disciplinary point-of-care ultrasonography (POCUS) in remote rural medicine. Subjects and Methods: Subjects were patients who underwent POCUS by a local physician because of a certain complaint or physical sign to determine whether to refer them to a secondary or tertiary medical center. We evaluated the decision to refer or not refer patients after POCUS, the validity of referrals, and outcomes based on the medical records. Results and Discussion: In a span of 1 year, about 136 patients underwent POCUS. The 164 identified symptoms were categorized as 30 (18.3%) musculoskeletal pain, 20 (12.2%) abdominal pain, and 11 (6.7%) fever, and the 165 locations of POCUS were 49 (29.7%) abdomen, 46 (27.9%) musculoskeletal system, and 35 (21.2%) heart. Based on the POCUS results, 56 patients (39.7%) were referred, while 80 (58.8%) were not referred and managed in the clinic. The referral was appropriate in 35 patients (87.5%), while the referral was unnecessary in five (6.8%). The outcomes of those who were not referred were as follows: 61 (82.4%) improved, eight (10.8%) unchanged, and five (6.8%) worse. Conclusion: Cross-disciplinary POCUS in rural medicine helps medical practitioners make referral decisions, reduces the burden on patients of going to a remote hospital, and brings them the needed treatment promptly.

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We report a case of chronic type B aortic dissection in a 70-year-old man. At an outpatient hospital, he was found to have an expanded dissecting descending aortic aneurysm and was transferred to our hospital for thoracic endovascular aortic repair (TEVAR). A stent graft was successfully placed in the proximal descending thoracic aorta (DTA) to close the primary entry. Postoperative computed tomography (CT) revealed persistent contrast enhancement of the false lumen in the DTA that was suggestive of an endoleak. However, the origin and flow direction of the endoleak were uncertain, and classification of the endoleak was difficult. Hence, the echocardiographic paravertebral approach (PVA) was performed. Both the true lumen and false lumen were clearly visualized and retrograde flow from the intercostal artery into the false lumen was demonstrated by color Doppler examination. These findings suggested that the endoleak originated from the intercostal artery (type II) rather than the proximal end of the stent graft (type Ia). Hence, it was concluded that the patient should be observed conservatively. Follow-up CT at 8 months post-TEVAR showed no expansion of the maximal diameter of the DTA. In this case, the utility of PVA for detection and classification of an endoleak after TEVAR was confirmed.

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