Hone your POCUS interpretation and clinical reasoning by working through the interactive case below.
Case #14: Not a Belly Good Sign
Mr B is an 80-year-old male who was admitted for an elective cholecystectomy. Past medical history is significant for CKD, CAD, PVD, T2DM, HFpEF, pulm HTN with PASP 55, and atrial fibrillation.
Intra-operatively, he received 450cc of IV fluids. Post-operatively, he required 1L of oxygen to maintain saturations. The surgery was not complicated, and saline was used to wash the peritoneum.
CXR on POD#1 reported “Stable small bilateral pleural effusions and mild left basal atelectasis.” His JVP was noted to be elevated, and he was restarted on home dose furosemide 80 mg PO daily. He also developed an AKI, which continued to worsen with diuresis. He has been hemodynamically stable with no perturbance charted.
Cr admission 200 —> 248 —> 352 —> 376. Hb noted to have reduced from 115 to 65 that morning.
POCUS was consulted by IMPCT (Internal Medicine Perioperative Service) on POD#3 for volume assessment in the context of hypoxia and AKI.
He was alert, cooperative, coherent. High BMI. Nil presyncope, dyspnea at rest.
Right IJV at 2cm ASA with HOB 30 degrees
Representative image of his lung fields
Abdominal Pocus
Locating the IVC was challenging, during which the following was noted:
Right flank
Left upper quadrant
You proceed to scan his right lower quadrant
Overall Impression
POCUS exam was not consistent with cardiogenic pulmonary edema as the cause of patient’s hypoxia.
The visualized abdominal free fluid was concerning for hemoperitoneum.
The blood loss and diuresis likely resulted in hypovolemia and hemodynamic AKI from renal hypo-perfusion.
Findings were discussed with the Perioperative Service. CT abdomen requested.
Case Resolution
Urgent CT abdomen: Mild to moderate hyperdense ascites consistent with hemoperitoneum was identified extending from the right subphrenic space along the lateral right liver lobe within the right paracolic gutter into the pelvis. A small amount of hemoperitoneum was noted within the left paracolic gutter. Two adjacent right-sided mesenteric hematomas were identified measuring 3.2 cm x 2.5 cm medially (3:101) and 5.5 cm x 3.2 cm laterally.
Given these findings, patient was taken back to OR for diagnostic laparotomy and evacuation of the clots.
Can you differentiate blood vs ascites on POCUS?
It is challenging to evaluate the etiology of intra-peritoneal free fluid based on POCUS findings alone. Ascites, blood, bile, and urine may all appear as anechoic fluid. Infectious or malignant ascites may appear more echogenic, have septations, and fibrin stranding. Clotted blood may appear echogenic and have a layered appearance. Clinical correlation and paracentesis are essential tools in the work up of intra-peritoneal free fluid.
Of note, a FAST exam’s sensitivity for intra-peritoneal free fluid is reduced in hemodynamically stable patients, though its high degree of specificity in the appropriate clinical context is preserved.
Malignant ascites - note the echogenic fluid with stranding.
Malignant ascites with extensive septations.
