We previously discussed about the reverberation artifacts in the abdomen resembling A-and B-lines seen on lung ultrasound. A-lines (not standard terminology in abdomen) or the horizontal reverberation artifacts are typically seen in pneumoperitoneum. In nephrology practice, it is common to see these after paracentesis in hepatorenal patients.

Here are images from a patient with heart failure in whom we were trying to find IVC/portal vein for volume status assessment. Interestingly, A-lines were seen all over the abdomen and liver/spleen could not be visualized. There was no history of recent abdominal procedures and the patient was not in pain. The abdomen was distended however. Vital signs were stable.

“Scissors maneuver” might be helpful to distinguish reverberation artifacts from pneumoperitoneum versus bowel. It involves applying slight pressure on top of the liver + A-lines with caudal end of the probe – this leads to displacement of the free air (pneumoperitoneum) and reverberation becoming less prominent. Now when the probe pressure is released, the free air returns and reverberations reappear. On real-time POCUS, this maneuver mimics the opening and closing of scissors, hence called the scissors maneuver. Below is a nice demonstration.