Non-Trauma Application of the Focused Assessment with Sonography for Trauma (FAST) Exam: Large Volume Hemoperitoneum due to Hemorrhagic Ascites from Ischemic Bowel

Document Type

Conference Proceeding - Restricted Access

Publication Date

5-9-2025

Abstract

Small bowel obstruction (SBO) is a common abdominal emergency, responsible for approximately 15% of hospitalizations in the United States. It is typically diagnosed with clinical evaluation, radiographs, and computed tomography (CT). When complicated by concern for gastrointestinal bleeding, a CT-angiogram can identify potential sources of hemorrhage. While providing detailed visualization of the abdominal vasculature, it can be time-consuming and delay treatment, which is especially risky in patients with hemodynamic instability. In such cases, the Focused Assessment with Sonography for Trauma (FAST) exam offers a rapid, non-invasive way to detect intraperitoneal free fluid and has been increasingly utilized for non-trauma applications. We present a case in which a FAST exam detected hemorrhagic ascites in the setting of SBO, leading to rapid surgical intervention and recovery.

A 72-year-old female with a past medical history of hypertension, gastroesophageal reflux disease, and diverticulitis (sigmoidectomy 1-2 years ago) presented with upper abdominal discomfort, nausea, and vomiting. She was transferred from an outside hospital due to suspected mesenteric ischemia. On arrival, she was normotensive, afebrile, and had normal heart and respiratory rates. Physical exam revealed tachycardia, generalized abdominal tenderness, and some rigidity, but no guarding, appreciable masses, or ecchymosis. The CT from the outlying hospital showed mesenteric stranding and a small amount of free fluid. General surgery was consulted for possible operative management. Repeat labs were obtained and revealed lactic acidosis and a drop in hemoglobin from 14.7 to 8.6 g/dL since transfer from the outlying hospital.

A FAST exam performed by the emergency department physician revealed significant intra-abdominal free fluid in the right and left upper quadrants, suggesting intra-abdominal hemorrhage. Given the acute blood loss anemia and positive FAST examination, general surgery agreed that the patient required emergent laparotomy. Two units of blood were transfused, and the patient was prepped for surgery. Unfortunately, due to communication errors, this patient was taken to obtain a CT angiogram prior to transport to the operating room. However, surgery had determined she required operative intervention without the CT angiogram results based on FAST exam and acute anemia on blood work. She underwent exploratory laparotomy and was found to have a closed loop SBO with hemorrhagic fluid of approximately 700 mL. 180 cm of small bowel was resected, and a primary anastomosis was performed. The patient recovered well and was discharged home on hospital day five, tolerating a regular diet.

In this case, the FAST exam played a crucial role in the rapid identification of hemorrhagic ascites in the setting of SBO, facilitating timely transfusion and surgical intervention. Had the ED physician relied on CT angiogram to identify the source of anemia, this could have delayed transfusion and time to surgical intervention. This highlights the utility of the FAST exam as an inexpensive, non-invasive, and timely way to detect intraperitoneal bleeding. Early recognition and intervention contributed to a favorable outcome and quick recovery for the patient

Comments

2025 Research Day Corewell Health West, Grand Rapids, MI, May 9, 2025. Abstract 1732

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