Patient with sub-acute presentation and rigid abdomen

We have had a few patient’s here recently with clearly surgical abdomen; Rigid and with peritonitis.

However, they often have a subacute history, 2-3 weeks is reported. Although, as mentioned previously, our history seem to be less accurate in Sierra Leone than back in the UK, but this seemed incongruent to me.

So, we undertook POCUS.

This a RUQ scan for the first patient. You can see the liver tip clearly.


Most folk will be used to seeing free fluid in the abdomen. However, you can see the fluid in this example is very speckled. This is the appearance you get with empyema in the lung. Making us suspect pus in the abdomen, likely perforation.


This is a second case, this is lower abdomen, just below umbilicus.



It is less clear as no organs for reference, but there is clearly black speckled material in the abdomen. This is not good.


Both cases were referred to surgical team for urgent laparotomy, a process sped up by a clear referral of “pus in the abdomen” although this is still a slow process and requires family to obtain money for this upfront. The first case unfortunately died whilst being transferred to theatre, the second patient was recovering well for his surgery at time of writing.

But why the delayed presentation?

Partially it is due to poverty, medical care is expensive here compared to people’s income so tend to present very late, often having tried over the counter or traditional methods first.

Also the aetiology is likely different. There is a high burden of Typhoid fever here, a complication of which is perforation, usually in theĀ  second or third week of the condition.


Learning points

1/ Be aware of your local conditions whilst working in a new location.


2/ Free fluid from perforation often has ultrasound signs; usually a speckled appearance.


3/Experience in one time of scan will help you in others, I was only able to recognise this confidentially after seeing lots of pulmonary empyemas.