Ultrasound Case 101


A 74 year old man presents with increasing fluid overload and hypotension. He has small complexes on his ECG and you are asked to assess for a pericardial effusion. There is lots of fluid, can you describe where it is?

Describe and interpret these scans

Image 1: Subcostal cardiac view.

There is no significant pericardial effusion.

There is marked ascites with fluid below the diaphragm and a falciform ligament undulating in the fluid. There is a trivial amount of pericardial fluid. The LV is dilated and poorly functioning, and the LA also dilated. There is a very large right sided pleural effusion. The aerated left lung lies against the pericardium posteriorly and left pleural effusion is not seen in this view. Other views would be better to determine the presence of a left pleural effusion.

LITFL Ultrasound Case 101 Key

Large volume ascites. Poor LV function. Right pleural effusion.

This case is about understanding the diaphragm and inferior pericardium are fused. When there is a large amount of ascites it can lie against the inferior surface of the diaphragm. This should not be confused for pericardial fluid which lies above the diaphragm and surround the heart.

To tell the difference:

  1. Identify the pericardium
  2. Determine whether the fluid lies between it and the heart and follows the curves of the heart.
  3. Or whether you can trace the fluid below the diaphragm, into the lateral recesses of the abdomen.
  4. Look for other evidence of pericardial effusion and its effects such as pressure effects on the RV.
  5. Look in other views – at the heart, the abdomen, the lungs.
Image 3 The pericardium

Key Points:

  • Do not confuse pericardial fluid and ascites.
  • Do no confuse pericardial fluid and a left pleural effusion – which lies posterior to the left heart on the parasternal long axis view.
  • Remember fluid is not always hypoechoic.
  • Blood, pus and proteinaceous material causes fluid to be more echogenic – and the echogenic debris may be fine or more coarse and particulate, depending on its nature.



An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

One comment

  1. Ha, I just fell for this on my CCFP-EM exam last week. The image in the exam looked odd and didn’t really fit clinical scenario and the picture was all of 8cm on my screen (and I’m old and losing my vision). Ironic to see this post AFTER writing my exam..

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