Case #10: Abdominal Pain
Mounica Robsinson, M.D.
HPI: 55 yo female presents with diffuse abdominal pain, 1 day history of green/brown emesis and generally feeling unwell . She also endorses weight loss for the past 2-3 months and abdominal distention over the past few weeks. She has no other medical history.
Physical Exam:
Gen: thin in appearance, weak/fatigued
Abd: abdominal distention, diffusely tender with no localizing pain
Labs:
WBC count: 65,000
Procalcitonin: 1.62
Plts: 580
Lactate: 3.1
Bedside Ultrasound:
hat is in these views?
What structures do you see?
What is abnormal about this ultrasound?
Other Imaging: CT abdomen/pelvis showed 6.9 x 7.9 cm mass left upper quadrant likely originating from the tail of pancreas, contiguous with and likely infiltrates the spleen and the left kidney. Complete replacement of the liver with large metastatic masses. Small amount of ascites. Basilar lung infiltrates and small left effusion.
Diagnosis: Abdominal Ascites 2/2 Malignancy
Ultrasound Education:
When is a FAST indicated?
- any clinical situation in which there is clinical concern for intra-abdominal free fluid or hemorrhage
- most often in blunt or penetrating cardiac and abdominal trauma
- can also be used to evaluate for ascites in a medical patient with known liver disease or suspected malignancy
Where does fluid first collect in the abdomen?
- Morrison’s pouch
What does free fluid in the abdomen indicate?
- in the right clinical setting, free fluid can suggest possible malignant ascites
- can also indicate:
- hemorrhage from traumatic organ injury
- leakage of bowel content/bile from hollow viscus injury
During the FAST exam, the patient lies supine.
The 4 views of the FAST exam include:
1) RUQ (Morrison's pouch)
2) LUQ (Splenorenal recess)
3) Suprapubic area
4) Subxiphoid area (pericardium)
Additional resources:
Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5305137/
SonoTutorial: The FAST Part 1: The right upper quadrant – the right way to do it
Evaluation of Ascites and its Etiology Using Ultrasonography