A 79-year-old male smoker with arterial hypertension was admitted to a coronary unit with a sudden onset of constant left sided thoracic pain. The pain radiated to the back and the left shoulder, it worsened with movement and cough. During the transport to the hospital the patient received oxygen, oral nitro-glycerine and aspirin with some effect on the pain. At the arrival to the coronary unit, he was found in acute pain. The respiratory and heart rate was increased. Blood pressure, saturation, temperature and heart and lung auscultation were normal. On examination of the abdomen, the patient did not complain of any pains. There was no guarding and few abdominal sounds. The ECG showed sinus rhythm and no signs of heart ischemia. Treatment with low molecular heparin and clopidogrel was initiated on the suspicion of acute myocardial infarction.
Two hour later, the patient was reexaminated. The patient now had slight pain when he was palpated in the upper left quadrant of the abdomen. Still no guarding was present. The available blood tests showed an elevated total white blood cell count (22.5 × 10E9/l), thrombocytosis (516 × 10E9/l), slight anaemia (6.5 mmol/l) and elevated carbamide (13.4 mmol/l). C reactive protein, creatinine, potassium, natrium, amylase and troponine T all showed normal values.
As a part of the secondary evaluation FATE including ultrasonographic examination of the pleura and lungs was performed. At position 1 (subcostal), the heart and liver could not be visualised. Instead the peritoneum could be seen as a hyperechoic stripe, corresponding horizontal reverberation artefacts was visible under the peritoneal line (Fig. 2). At position 2 and 3 (apical and parasternal) of the FATE protocol, the heart could be visualised. There was no pericardial effusion or other signs of pathology. Chamber dimensions were normal. The left ventricle was well filled and the ejection fraction was judged to be normal. Sonographic examination of the lungs and pleura, showed normal lung sliding, no B-lines, periphery alveolar consolidation, atelectasis or effusion.
Based on the findings from the subcostal view, a conventional X-ray image of the abdomen with the patient in the left lateral decubitus position was taken. The X-ray confirmed the diagnosis of pneumoperitoneum. The patient was transferred to a surgical unit where he was operated for a perforated ventricular ulcer.