CM: August 2015

August 2015 Case of the Month

The Case

The patient is a 56 –year-old Caucasian male who presents to the Emergency Department via EMS with abdominal pain of 1-hour duration. The patient was at home with family when he experienced sudden onset of severe abdominal pain, causing him to collapse to the floor. The fall was controlled, and the patient did not hit his head, and denies LOC. The patient states the pain began as a sudden, sharp pain in the epigastrium, which quickly generalized to his entire abdomen, and now feels pain also in both shoulders. The patient has a history of osteoarthritis, and his only medications are NSAIDs for the aforementioned medical condition. The patient’s temperature is 98°F, pulse is weak at 116 beats/min, blood pressure is 104/70 mmHg, and O2 sat of 98 on room air. Physical examination reveals cool, clammy skin. Palpation of the patient’s abdomen demonstrates marked board-like rigidity. Plain film x-rays are unremarkable. You decide to access the patient’s complaint using ultrasound. With the patient in a supine position you place an ultrasound probe at first gently on the patient’s abdomen in the epigastric area, and you see the image on the left. You increase steady pressure with the ultrasound probe and see the image on the right.


Suggest Resources:

Chao, A., Gharahbaghian, L., and Perera, P., (2015). Diagnosis of Pneumoperitoneum with Bedside Ultrasound. West Journal of Emergency Medicine, 16(2): 302.

Karahan, O. I., Kurt, A., Yikilmaz, A. and Kahriman, G. (2004), New method for the detection of intraperitoneal free air by sonography: Scissors maneuver. Journal of Clinical Ultrasound, 32: 381–385.

Behrman, S.W. (2005). Management of complicated peptic ulcer disease. Archives of Surgery. 140 (2):201-208.

Bertleff M.J, and Lange J.F (2010). Perforated Peptic Ulcer Disease: A Review of History and Treatment. Digestive Surgery, 27; 161-169.

The Quiz

Q: What does the scan demonstrate? A: Free air within the abdominal cavity

Q: What is the most likely precise clinical etiology in this patient? A: perforated peptic ulcer

Q: What is the most appropriate initial step in clinical management? A: Immediate surgical consultation

Bonus question ! Q: What does the scan on the left remind you of? A: A lines seen in ultrasound of the lungs.

August’s Winner:

Congratulations to Paul VandeKoppel our winner of the Case of the Month! Enjoy your Starbucks winnings!!


-Pneumoperitoneum describes gas in the peritoneal cavity.

-The most common cause is a disruption of the wall of a hollow viscus, which can occur in the setting of many disease, or traumatic processes, including peptic ulcer disease complicated by perforation. (Other causes include: appendicitis, diverticulitis, ischemic bowel, bowel obstruction, mechanical ventilation, peritoneal dialysis).

-Ulcer perforation should be suspected in patients who develop diffuse abdominal pain.

-Perforations occur in 2-10% of peptic ulcers.

Perforated peptic ulcers present in 3 clinical stages:

Initial phase (within 2 hours of onset): This stage may last a few minutes or up to 2 hours. The onset is sudden as perforation results in acidic fluid interacting with peritoneum. The severity depends on how much fluid is released.

Tacycardia, weak pulse, cool extremities and low temperature are often noted. Pain may radiate to the right shoulder or both shoulders.

Second phase (2-12 hours after onset): Abdominal pain may lessen, but abdomen remains rigid. RLQ tenderness may develop as fluid collects in the paracolic gutter. Pelvic peritoneum palpated upon rectal exam is often tender due to inflammation of peritoneum.

Third phase (>12 hours after onset): Increased abdominal distension, but pain, tenderness and rigidity less evident. Cardiovascular collapse, with third spacing, hypovolemia, and temperature elevation often seen. Perioperative delay >12 hours is associated with poorer outcomes.

-Rapid diagnosis is essential as prognosis is excellent within the first 6 hours of onset.

-Perforation of a peptic ulcer is largely a clinical diagnosis, based on HPI, physical findings and risk factors.

US has a sensitivity of 85% and a specificity of 100% for pneumoperitoneum. It has been shown in some studies to have a higher sensitivity for this diagnosis as compared to plain radiography.

-However, CT remains the gold standard imaging tool for diagnosis of puemoperitoneum.

-low and high frequency probes can be used.

-patients can be evaluated in the supine position, with interrogation of the anterior abdomen, or they can be moved into a left lateral decubitus position, and the perihepatic space can be evaluated.

Enhanced peritoneal stripe sign (EPSS) in conjunction with reverberation artifacts indicate free air in the peritoneal cavity.

-the ‘scissor maneuver’ (no compression, followed by compression) can increase the sensitivity of US to detect pneumoperitoneum.

Treatment and Management

-immediate surgical consultation

-Insertion of NG tube

-IV fluids


-broad spectrum antibiotics


CHECK OUT our April 2014 Case of the Month: Rush Protocol

Suggested Resources:

Academic Life in EM: “RUSH protocol: Rapid Ultrasound for Shock and Hypotension

Introduction to Bedside Ultrasound: Vol. 1, Ch. 5 “RUSH”

Mount Sinai Ultrasound: “RUSH

CHECK OUT our March 2014 Case of the Month: Soft Tissue Ultrasound

Suggested Resources:

One Minute Ultrasound: Soft Tissue

SonoGuide: Abscess AND Soft Tissue Ultrasound

Introduction to Bedside Ultrasound: Vol. 2 Ch. 10 “Soft Tissue”

March’s Winner:

Congratulations to Sooyeon Kim our winner of the Case of the Month! Enjoy your Starbucks winnings!!


CHECK OUT our February 2014 Case of the Month:

Vascular Access Ultrasound

Suggested Resources for Vascular Access Ultrasound:

Introduction to Bedside Ultrasound: Vol. 2 Ch. 8

Ultrasound Podcast: Ultrasound-Guided Peripheral IV

ACEP Clinical Practice and ManagementDynamic Ultrasound-Guided Peripheral Intravenous Line Placement

February’s Winner:

Congratulations to Joe Chiles our winner of the Case of the Month! Enjoy your Starbucks winnings!!