Presented with abdominal swelling, but what is the real problem?

In our population here in Freetown, the history can be a little unreliable and difficult to interpret at times.

This gentleman in his 60’s main complaint was abdominal swelling, the doctor seeing him had requested formal abdominal ultrasound and prescribed antibiotics and fluids.

Clearly from the end of the bed you could see he was grossly fluid overloaded. I was teaching at the time and Dr Daniel Sesay, a house officer with only a few days POCUS experience, took the following images.


An apical 4 chamber view



And a slightly off centre Parasternal short axis view, due to his cardiomegaly the probe marker had to moved quiet inferiorly and laterally, hence tthe off centre view.



Even for the inexperienced you can see the dilated ventricles bilaterally and the poor contractility.


But what to make of the presenting complaint?

Well we continued with a view of the abdomen

This RUQ view demonstrates free fluid in the abdomen, you can see the liver tip come into view as the patient breathes.

In addition on the lung view you can see fluid both above and below the diaphragm


It was clear that this patient had anasarca, whole body swelling, secondary to heart failure.

So I showed the clerking doctor this images and suggested that IVU fluids are not be appropriate and furosemide would be the mainstay of treatment acutely.

He was admitted and improved after a few days of diuretics and was discharged with outpatient follow up. Although the admitting team still felt abdominal investigations necessary.

Learning points

  • In low resources settings patients can present very late in the course of chronic disease.
  • Sometimes we have to be sceptical of presenting complaints, what our patients complain of may not be the main problem!
  • Obtain cardiac view and identify grossly abnormal pathology is simple, we do not always need the standards of a formal echo when we start learning and often can obtain useful information with simple scans.