A 72-year-old man with a medical history of hypertension and gastrointestinal bleeding presented to the emergency department (ED) with abdominal pain, coffee ground emesis, and weakness that began 3 hours prior to arrival. Vital signs were blood pressure 82/44 mm Hg, pulse 118 beats/min, respirations 22 breaths/min, temperature 97.2°F, and oxygen saturation 94% while breathing room air. Physical examination revealed mild respiratory distress and diffuse abdominal tenderness with guarding and rebound.
During the initial stabilization of the patient, an upright portable chest radiograph was obtained (Figure 1) but did not demonstrate evidence of pneumoperitoneum. Given the high suspicion for pneumoperitoneum, a bedside focused assessment with sonography in trauma (FAST) ultrasound examination was performed by the treating emergency physician using a low-frequency 5–2 MHz curvilinear transducer (SonoSite MTurbo, Bothell, WA). This demonstrated free intraperitoneal fluid in Morison’s pouch (Video Clip S1). Upon attempting views of the pelvis, distinct hyperechoic foci with reverberation artifacts were visualized within the free fluid, suggesting associated free intraperitoneal air (Video Clip S2). Surgical consultation was immediately obtained and a noncontrast computed tomography exam of the abdomen and pelvis was performed, confirming free intraperitoneal fluid and pneumoperitoneum (Figure 2). The patient was taken emergently to the operating room, where a large posterior gastric perforation was identified and repaired.