PMC4844665_01
A 90-year-old man presented with a tender irreducible epigastric mass (Fig. 1A). Surgeon performed Point-of-care Ultrasound (Fig. 2B) showed that it was a hernia containing small bowel (SB) which was strangulated because of the narrow neck of the hernia (yellow arrow heads). Colour Doppler showed no flow in the mesentery of the bowel (black arrow).
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On abdominal examination, the mass was tender and irreducible (Fig. 1A). Colour Doppler showed no flow in the mesentery of the bowel (Fig. 1B).
Surgical exploration of the hernial sac showed that the strangulated small bowel was dusky, haemorrhagic and not contracting (Fig. 2A). Ten cm of the small bowel was resected and end-to-end anastomosis was performed (Fig. 2B).
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The strangulated small bowel was dusky, haemorrhagic and not contracting (Fig. 2A). End-to-end anastomosis using vicryle 3/0 was performed (Fig. 2B).
A routine follow Point-of-care Ultrasound by a portable ultrasound machine (Fig. 3A) showed significant intra-peritoneal fluid (F) although the patient was haemodynamically stable. Using a linear probe with a frequency of 10-12 MHz (Fig. 3B), the intra-peritoneal fluid turned out to be heterogeneous. The deep areas of the fluid were more echogenic indicating clotted blood (C). The fluid (F) was tapped under ultrasound guidance (hashed arrow) and it was frank blood.
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24 h after surgery, in a routine follow up using POCUS, post-operative intra-peritoneal fluid was seen (about 1.5 L) (Fig. 3A). It was frank blood (Fig. 3B).
Preoperative IVC measurement (82 mm) showed that the patient was hypovolaemic (Fig. 4A). Aggressive resuscitation using crystalloids, blood and fresh frozen plasma was performed under repeated measurement of IVC diameter. IVC increased to 164 mm (Fig. 4B). The patient blood pressure increased from 40/20 mmHg to 110/70 mmHg.
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Damage control resuscitation was performed under inferior vena cava sonographic measurement till blood pressure picked up quickly (Fig. 4A-B).