Jonathan T. Jaffe
Casey D. Bryant
John P. Gaillard
1. A 56-year-old man with a history of peptic ulcer disease and cirrhosis is admitted to the Emergency Department for abdominal pain. His vital signs are temperature 38.2°C, HR 114 bpm, BP 97/54 mm Hg, RR 22/min, and SpO2 93% on 2 L nasal cannula. He is in mild distress with clear lungs and a distended abdomen that is diffusely tender to palpation. He is given a 30 mL/kg bolus of lactated Ringer’s solution and started on broad-spectrum antibiotics, with a plan to perform a diagnostic paracentesis. During the preparation for the procedure, Figure 76.1 is obtained from the left lower quadrant.
What is the most appropriate next step in his management?
A. Proceed with paracentesis
B. Surgical consultation
C. Evaluate other sites for paracentesis
D. Computed tomography (CT) abdomen/pelvis
1. Correct Answer: B. Surgical consultation
Rationale: Figure 76.1 shows an abdomen with free air and ascites. Although the patient is at risk for spontaneous bacterial peritonitis, this presentation is much more concerning for perforated viscus and emergent surgical consultation is most appropriate (Choice B is correct). Although the diagnosis of perforated viscus is not commonly made with ultrasound, it is important to recognize air when it is seen. It most often appears as an echogenic stripe representing the peritoneum associated with deep artifactual reverberation echoes with a comet tail appearance. Detection can be operator-dependent and certain patient maneuvers and positions, such as deep breathing and left lateral decubitus position, can be helpful. One study found the sensitivity of ultrasound for free air in acute abdominal pain patients to be 85% and the specificity to be 100%, making it a valuable diagnostic tool. With this finding, paracentesis should not be performed (Choices A and C are incorrect). Although a CT scan would be helpful in confirming the presence of intraperitoneal air and may be able to identify the source of the injury, the decision to perform more diagnostic testing should occur after surgical consultation in an acutely ill patient with generalized peritonitis, as delays in surgery may be associated with worse survival (Choice D is incorrect).
1. Bohnen J, Boulanger M, Meakins JL, McLean APH. Prognosis in generalized peritonitis: relation to cause and risk factors. Arch Surg. 1983;118(3):285-290. doi:10.1001/archsurg.1983.01390030017003.
2. Hefny AF, Abu-Zidan FM. Sonographic diagnosis of intraperitoneal free air. J Emerg Trauma Shock. 2011;4:511-513. doi:10.4103/0974-2700.86649.
3. Moriwaki Y, Sugiyama M, Toyoda H, et al. Ultrasonography for the diagnosis of intraperitoneal free air in chest-abdominal-pelvic blunt trauma and critical acute abdominal pain. Arch Surg. 2009;144(2):137-141. doi:10.1001/archsurg.2008.553.
2. A 62-year-old woman with a history of alcoholic cirrhosis presents to the Emergency Department with abdominal distension and fever. Her vital signs show a temperature of 38.5°C, HR 110 bpm, BP 97/54 mm Hg, RR 20/min, and SpO2 95% on 2 L nasal cannula. Her abdomen is tense and diffusely tender, prompting a clinical concern for spontaneous bacterial peritonitis. During preparation for a diagnostic paracentesis, Figure 76.2 is obtained.
What is the next best step in her management?
A. Evaluate different sites for paracentesis.
B. Proceed with paracentesis at this location.
C. Evaluate with color flow Doppler.
D. Refer procedure to Interventional Radiology.
2. Correct Answer: A. Evaluate different sites for paracentesis
Rationale: Figure 76.2 shows a vessel above the large pocket of ascites. Although placing color on Figure 76.2 could confirm this, it is not necessary (Choice C is incorrect). It is likely that moving your probe a few centimeters would avoid the vessel and the procedure could be performed safely at the bedside (Choice A is correct; Choice D is incorrect). Generally, paracentesis is performed with a low-frequency curvilinear probe, but it is reasonable to use a high-frequency linear probe to help identify superficial vasculature, which could contribute to additional bleeding from the procedure. Blind techniques for paracentesis utilize either the infraumbilical midline or the lower quadrants superior and medial to the anterior superior iliac spine to avoid the inferior epigastric vessels. Ultrasound allows entry sites at other parts of the abdominal wall, provided that vessels are actively avoided. This vessel could easily be punctured with a paracentesis attempt, inadvertently leading to the creation of an abdominal wall hematoma (Choice B is incorrect).
1. Ennis J, Schultz G, Perera P, Williams S, Gharahbaghian L, Mandavia D. Ultrasound for detection of ascites and for guidance of the paracentesis procedure: technique and review of the literature. Int J Clin Med. 2014;05(20):1277-1293. doi:10.4236/ijcm.2014.520163.
2. Nicolaou S, Talsky A, Khashoggi K, Venu V. Ultrasound-guided interventional radiology in critical care. Crit Care Med. 2007;35(5 suppl.). doi:10.1097/01.CCM.0000260630.68855.DF.
3. Runyon MS, Marx JA. Peritoneal procedures. In: Roberts JR, Custalow CB, Thomsen TW, Hedges JR, eds. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th ed. Elsevier/Saunders; 2014:852-872.
3. A 55-year-old man with a history of hepatitis C is admitted to the hospital for shortness of breath and abdominal distension. His is nontoxic appearing and states that his symptoms are similar to the symptoms he had 2 weeks ago when a paracentesis was performed to remove 5 L of ascites. Prior to the procedure, Figure 76.3 is obtained.