Jelly Belly
Submitted by: Chad Lange, MD and Teresa Wu, MD
A 56 year-old male arrives in the ED with a chief complaint of diffuse abdominal pain, fevers, chills, nausea, vomiting, and general weakness. His past medical history is significant for diabetes, hypertension, hypercholesterolemia, GERD, some “liver problems” and some “kidney problems”. He has not been able to afford to see his physician in “quite some time” and he is starting to run out of his medications.
On exam, he is febrile to 38.6 degrees celcius, his BP is 112/67 mmHg, his HR is 107, his RR is 20, and his O2 saturation is 97% on RA. His physical exam is notable for a distended abdomen that is warm to the touch. He is diffusely tender to palpation and you elicit voluntary guarding with deep palpation.
You perform a bedside, focused ultrasound of his abdomen with the curvilinear transducer.
What do you see on this view?
What procedure should you perform?
How can bedside ultrasound help you during the procedure?
The patient’s ultrasound demonstrates hyperechoic loops of bowel floating in anechoic intraperitoneal fluid. The patient has a significant amount of ascites visible on the scan. Based on the patient’s symptoms and physical exam findings, he will need a paracentesis to evaluate for spontaneous bacterial peritonitis.
Bedside ultrasound can be used to evaluate for the presence or absence of intraperitoneal free fluid. If the patient has ascites present, you can use bedside ultrasound to determine the best location to perform a paracentesis. Scan around the patient’s abdomen until you find the largest collection of fluid away from vital organs such as the liver, spleen, and bladder.
Use the hash marks on the right side of the ultrasound image to help you determine how much room you have to advance your needle and catheter during the paracentesis. On the image shown here, each hashmark represents 1 cm. During the procedure, you can advance your needle approximately 4 to 5 cm before approaching floating bowel. An ultrasound-guided paracentesis can be performed in the static fashion or under direct dynamic ultrasound guidance.
