An 82-year-old patient underwent surgery for intestinal ischemia (superior mesenteric artery). Resection of part of ileum was performed, both ends were closed (not connected to each other). Surgical revision was necessary for diffuse bleeding into the abdominal cavity on day 1. After two more days, end-to-end anastomosis was established. On day 7 (after re-anastomosis) the abdomen was still diffusely sensitive at its inferior half. No sign of peritoneal irritation was present. There were persisting increased levels of inflammatory markers. Drains were removed, diarrhoeic stool (tests for toxin as well as for antigen of Clostridium difficile were both negative). The patient was receiving the almost whole amount of nutrition via a nasogastric tube. No reflux occurred. Auscultation revealed peristalsis. The patient had been receiving antibiotic therapy for pneumonia from day 3 (microbiological cultivation of samples from bronchoalveolar lavage revealed E. coli and E. faecalis with good sensitivity to empiric antibiotic treatment). The question was whether another focus of infection could be present in the abdomen.
Abdominal ultrasonography was performed. It was difficult to perform ultrasonography at midline due to recent laparotomy. The patient was in the semi-sitting position: