I recently saw a patient with an acute abdomen. Elderly, hypotensive, severe abdominal pain. Vast number of co morbidities. Initially, I thought he was septic, and began treatment as such.
After further investigation and examination, I couldn’t shake the feeling that my intial diagnosis had been wrong. So I’d gone back, reassessed the patient, and re examined them. I decided to speak ton the consultant, as I felt that the patient might have an ischaemic bowel, or perhaps a leaking AAA.
The patient had crashing renal failure, creatinine was up near 1000. Radiology were unwilling to perform a double contrast scan (I know, I know, contrast doesn’t cause nephropathy, but that fight was for another day). We discussed that this patient was unlikely to benefit, as they were not going to be fit for surgery, and if this was ischaemic bowel or a leaking AAA, then the patient would be for palliative management.
So I discussed the patient with the surgeons, and my consultant, and we all agreed. However, we felt we should investigate what we could, and I went to ultrasound the patients abdomen, looking for a AAA.
What I saw, after several sessions in a AAA scanning clinic, with all my new found skills, was nothing. A bright, echogenic line just below the skin, obscuring any aorta that may have been there, aneurysmal or not.
I got the consultant, and asked them to have a look, and they found the same.
A few days later, I was listening to the 5 minute sono podcast by Dr Jacob Avila, and he discussed the Enhanced Peritoneal Stripe Sign, a sign of free intraperitoneal air. Bingo. I looked it up, looked up some of the papers, and looked up some scans of it on google. Exactly what we’d seen with my patient.
This was a case of knowledge failure on my part. If I’d known that sign, when I saw it I’d have been able to put a lot more weight behind the diagnosis of ischaemic bowel, with evidence of free intra abdominal air. As always, I just need to keep on learning.
I shared this with my consultant, who also didn’t know about it (or was just trying to save myego by saying that).
The links are below, and are well worth reading if you plan on ultrasounding abdomens.