An 81-year-old woman presented to the emergency department with a 4-day history of generalized abdominal pain. She denied fever, vomiting, and diarrhea. Physical examination revealed diffuse abdominal tenderness without guarding or rebound tenderness. Her medical history was significant for multiple comorbidities, including diabetes mellitus, hypertension, and stage 3 chronic kidney disease. Chest radiography demonstrated free air beneath both hemidiaphragms (Fig 1). Point-of-care ultrasound (POCUS), performed using both curvilinear and linear transducers, revealed intra-abdominal reverberation artifacts and the enhanced peritoneal stripe sign.1,2 (Figure 2, Figure 3, Figure 4; Videos 1–3). Axial computed tomography images of the abdomen subsequently confirmed the presence of free intraperitoneal air (Fig 5).
Video 2.
Probe abdomen enhanced peritoneal stripe sign.
Video 3.
Probe vascular A-line reverberation.
Figure 1.
Chest x-ray showed free air beneath both hemidiaphragms.
Figure 2.
POCUS performed with a curvilinear probe showed intra-abdominal reverberation artifacts (yellow arrow; peritoneum with an EPSS, next to the white arrowhead; reverberation artifacts caused by intraperitoneal free air). EPSS, enhanced peritoneal stripe sign; POCUS, point-of-care ultrasound.
Figure 3.
POCUS performed with a linear probe showed a transition zone in the anterior abdomen; normal peritoneum on the left (yellow arrow) and EPSS on the right (arrowhead). EPSS, enhanced peritoneal stripe sign; POCUS, point-of-care ultrasound.
Figure 4.
POCUS performed with a linear probe showed an EPSS (yellow arrow) with reverberation artifacts (next to the arrowhead).3 EPSS, enhanced peritoneal stripe sign; POCUS, point-of-care ultrasound.
Video 1.
Probe abdomen A-line not moving.
Figure 5.
Axial CT image of the abdomen demonstrated the presence of free intraperitoneal air (arrowhead). CT, computed tomography.
2. Diagnosis: Gastric Perforation at The Pyloroduodenal Junction
The patient was diagnosed with a gastric perforation at the pyloroduodenal junction. Subsequently, an emergency laparoscopic repair was performed utilizing a primary suture closure technique.
Although chest radiography (CXR) has traditionally served as the initial imaging modality for detecting pneumoperitoneum, recent data show that POCUS, specifically through the identification of the enhanced peritoneal stripe sign, demonstrated superior sensitivity compared with CXR (93% vs. 79%) while maintaining comparable specificity (64%).4 Consequently, POCUS represents a valuable bedside screening tool that facilitates rapid assessment and serial examinations. Nevertheless, positive sonographic findings warrant confirmatory abdominal CT when feasible. Computed tomography remains the diagnostic gold standard, offering a sensitivity of 96% to 100% and accurately localizing the gastrointestinal perforation site in 80% to 90% of cases to guide definitive surgical management.5
Funding and Support
By JACEP Open policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist.
Declaration of Generative AI and AI-Assisted Technologies in the Writing Process
During the preparation of this work, the author(s) used ChatGPT to enhance the academic English of this manuscript. The author(s) reviewed and edited the output as needed and take full responsibility for the content of the published article.
Conflict of Interest
The author has affirmed they have no conflicts of interest to declare.
Footnotes
Supervising Editor: Bryan Frailey, DO
References
- 1.Taylor M.A., Merritt C.H., Riddle P.J., Jr., DeGennaro C.J., Barron K.R. Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound. Ultrasound J. 2020;12(1):52. doi: 10.1186/s13089-020-00195-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Menegozzo C.A.M., Rasslan R., Damous S.H.B., Utiyama E.M. "Gut Point": POCUS leading to the detection of postoperative intestinal fistula. J Med Ultrasound. 2024;33(3):266–268. doi: 10.4103/jmu.jmu_129_23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Bacci M., Kushwaha R., Cabrera G., Kalivoda E.J. Point-of-Care ultrasound diagnosis of pneumoperitoneum in the emergency department. Cureus. 2020;12(6) doi: 10.7759/cureus.8503. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Chen S.C., Wang H.P., Chen W.J., et al. Selective use of ultrasonography for the detection of pneumoperitoneum. Acad Emerg Med. 2002;9(6):643–645. doi: 10.1111/j.1553-2712.2002.tb02307.x. [DOI] [PubMed] [Google Scholar]
- 5.Kumar A., Muir M.T., Cohn S.M., Salhanick M.A., Lankford D.B., Katabathina V.S. The etiology of pneumoperitoneum in the 21st century. J Trauma Acute Care Surg. 2012;73(3):542–548. doi: 10.1097/TA.0b013e31825c157f. [DOI] [PubMed] [Google Scholar]