Here is an interesting case shared by Pitt IMPOCUS. A middle-aged man with cirrhosis and history of venous thromboembolism on apixaban therapy presented with abdominal pain and distension. On examination, there was bilateral pitting pedal edema, distended abdomen with tenderness but no clinical signs of peritonitis. Laboratory data was significant for a serum creatinine of 2.2 mg/dL and a hemoglobin of 7.4 g/dL. No recent baseline available. POCUS demonstrated the following:

At first glance, it looks like there is ascites on this right upper quadrant image along with a simple renal cyst in the upper pole. Otherwise, nothing concerning. There was no evidence of pneumoperitoneum either (image not shown). More images shown below:

Now, it looks like the ascites is complex with internal echogenicities suggestive of an exudative origin. So, the likely diagnosis is spontaneous bacterial peritonitis?

Oh wait, what is this thing on top of the liver? Doesn’t seem to be a part of the liver. That in fact is clotted blood!! & the echogenicities are fibrin strands. So, the diagnosis is spontaneous hemoperitoneum in the setting of liver disease and oral anticoagulation therapy. Following image (oblique plane) demonstrates the ‘hematocrit sign’, which essentially means layering effect noted within large collections of extravascular blood when the collection separates into two gravity dependent layers with differing echogenicities.

Take-home point: Always consider the possibility of hemoperitoneum in a case of complex ascites, especially if there are risk factors for bleeding and/or there is drop on hematocrit. May also be seen after traumatic paracentesis. Compare this case to the previously discussed hemothorax.