PMC9983721_01
Parasternal long axis (left) and apical four chamber view (right). The left image shows a moderate sized pericardial effusion. In both images the walls were thickened and function was depressed towards the base of the heart. A subsequent echocardiogram described the findings as concerning for amyloid cardiomyopathy.
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Given the history of pericardial effusion we performed a point of care ultrasound (POCUS) of the heart, which showed a recurrent, moderately sized, simple effusion (Figure 1).
The left image shows the patient's IVC, which was plethoric, but also notable for scattered hyperechoic areas. The hyperechoic areas were confirmed in subsequent views of the liver (right) and lead to further investigation, as they are indicative of extensive portal venous gas.
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Quite striking, however, was the appearance of the surrounding liver, which had diffuse hyperechoic areas confirmed on multiple views (Figure 2). 
CT Abdomen showing gastric wall edema and gas in the peri-gastric vessels, some of which is highlighted in red.
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That CT showed gastric wall edema and gas in the peri-gastric vessels as the source of the portal venous gas (Figure 3).
CT Abdomen showing the large amount of gastric contents consistent with a bezoar, later confirmed to be a phytobezoar.
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A large gastric bezoar was also identified as potentially causal (Figure 4).