Saw this poor fellow recently who presented to the ED with fever and abdominal pain. 73 years young. He came to my attention because of borderline BP (95 systolic) and a lactate of 4.5 mmol.

Here is a transverse scan at his lower right costal margin:

 

What do you think?

Turns out he had been having pain for about two weeks, and it had intensified about two days ago. His wife dragged him in.

What would you do?

 

 

 

 

 

 

 

 

 

 

 

This is septated fluid collection around the liver.  With the fever and history, sounds pretty suspicious for a septic source. After carefully scanning in all angles and watching for a while to make sure this wasn’t a strangely placed loop of bowel, a 22g needle aspiration showed cloudy bilious fluid and a trip to the OR a couple of hours later revealed a perforated duodenal ulcer.

He made it ok.

 

cheers

 

Philippe