Case report
The double gut point: A case report of a novel sonographic sign of localized pneumoperitoneum
El doble punto visceral: un reporte de caso de signo precoz de neumoperitoneo localizado
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"Correa" ] 20 => array:2 [ "nombre" => "Mauricio" "apellidos" => "Vasco Ramírez" ] 21 => array:2 [ "nombre" => "Paula" "apellidos" => "Velasquez Trujillo" ] 22 => array:2 [ "nombre" => "Camilo Andrés" "apellidos" => "Bello Muñoz" ] 23 => array:2 [ "nombre" => "Daniel" "apellidos" => "Molano Franco" ] 24 => array:2 [ "nombre" => "Albert" "apellidos" => "Valencia Moreno" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0122726223000265?idApp=UINPBA00004N" "url" => "/01227262/0000002300000002/v1_202306081058/S0122726223000265/v1_202306081058/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0122726222000866" "issn" => "01227262" "doi" => "10.1016/j.acci.2022.12.001" "estado" => "S300" "fechaPublicacion" => "2023-04-01" "aid" => "384" "copyright" => "Asociación Colombiana de Medicina Crítica y Cuidado lntensivo" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Acta Colomb Cuid Intensivo. 2023;23:154-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Reporte de caso</span>" "titulo" => "Aféresis terapéutica en paciente con hígado graso agudo del embarazo: reporte de caso" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "154" "paginaFinal" => "159" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Therapeutic apheresis in acute fatty liver of pregnancy: A case report" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => 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En este caso existe normalización de los niveles de INR, de bilirrubina total y de creatinina, asociado a ascenso de fibrinógeno, evidenciando la mejoría progresiva de las funciones hepática, hematológica y renal. a)<span class="elsevierStyleHsp" style=""></span>INR; b)<span class="elsevierStyleHsp" style=""></span>fibrinógeno; c)<span class="elsevierStyleHsp" style=""></span>bilirrubina total; d)<span class="elsevierStyleHsp" style=""></span>creatinina.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisco Viera Molina" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Francisco" "apellidos" => "Viera Molina" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0122726222000866?idApp=UINPBA00004N" "url" => "/01227262/0000002300000002/v1_202306081058/S0122726222000866/v1_202306081058/es/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "The double gut point: A case report of a novel sonographic sign of localized pneumoperitoneum" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "160" "paginaFinal" => "163" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Yale Tung-Chen, Tomás Villén-Villegas, Elmo Pereira-Junior" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Yale" "apellidos" => "Tung-Chen" "email" => array:1 [ 0 => "yale.tung.chen@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Tomás" "apellidos" => "Villén-Villegas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Elmo" "apellidos" => "Pereira-Junior" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Internal Medicine Department, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Medicine Department, Universidad Francisco de Vitoria, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Intensive Care Department, Hospital Copa Star. Arbo Education, Río de Janeiro, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El doble punto visceral: un reporte de caso de signo precoz de neumoperitoneo localizado" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Abdominal pain is one of the most common presenting complaints to the Emergency Department (ED). The differential diagnosis is extensive, with many etiologies having the same initial presentation, which could change the management and therefore the prognosis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pneumoperitoneum can be a life-threatening situation, caused by hollow organ perforation. The first diagnostic approach is made with the help of abdominal or chest X-ray, however according to an early study, in almost 50% of cases, plain film radiography is unable to demonstrate pneumoperitoneum.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Abdominal CT, the gold standard investigation for pneumoperitoneum, is not always readily available and can be contraindicated in the setting of severe hemodynamic instability.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the diagnostic evaluation, Point-of-care ultrasound (POCUS) can be useful to distinguish between different conditions and guide early surgical intervention. It allows the practitioner to rule-in the presence of different conditions such as biliary disease, nephrolithiasis, gynecologic problems, bowel disease, vascular complications or existence of internal bleeding, which could modify the management or even set the indication of urgent surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The typical ultrasound findings in pneumoperitoneum are an enhancement of the peritoneal stripe sign (EPSS),<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> the presence of free fluid and a ring-down artifact that shift with patient position,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> these findings require a certain degree of expertise to detect.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0025" class="elsevierStylePara elsevierViewall">We herein report a case of a 90-year-old Caucasian man with previous history of hypertension, cholecystectomy, appendectomy and benign prostate hypertrophy, who presented in the ED with sudden increase in upper abdominal pain and distension.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient had been experiencing intermittent abdominal pain, vomiting and diarrhea for the past 3 days, unrelieved with omeprazole and loperamide, prescribed by his primary care physician. Physical exam showed abdominal rebound tenderness. He had a BP of 108/68<span class="elsevierStyleHsp" style=""></span>mmHg, Heart rate 96<span class="elsevierStyleHsp" style=""></span>bpm, axillary temperature 35.3<span class="elsevierStyleHsp" style=""></span>°C and SpO<span class="elsevierStyleInf">2</span> 96%. Laboratory workup was remarkable for WBC 12,100/μL [3700–11,600] (91% neutrophils; 3.9% lymphocytes), hemoglobin 9.8<span class="elsevierStyleHsp" style=""></span>g/dL [11.5–15.5], platelet 230,000/μL [150,000–400,000], Na 129.5<span class="elsevierStyleHsp" style=""></span>mmol/L [135–145], urea 217<span class="elsevierStyleHsp" style=""></span>mg/dL [10–40<span class="elsevierStyleHsp" style=""></span>mg/dL], ALT 34<span class="elsevierStyleHsp" style=""></span>IU/L [10–35], total bilirrubin 0.4<span class="elsevierStyleHsp" style=""></span>mg/dL [0.3–1.9], albumin 17<span class="elsevierStyleHsp" style=""></span>g/L [34–50], creatinine 6.1<span class="elsevierStyleHsp" style=""></span>mg/dL [0.7–1.3] (GFR 7.4<span class="elsevierStyleHsp" style=""></span>mL/mn/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> [>90]), CRP 382<span class="elsevierStyleHsp" style=""></span>mg/dL [0.0–3.0]. The rest of laboratory tests were normal. Decubitus abdominal X-ray was unremarkable.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was diagnosed with a small bowel obstruction (SBO) on ultrasound using a curvilinear probe (2–3<span class="elsevierStyleHsp" style=""></span>MHz), following a mowing-the-lawn technique (surveying the entire intestine, compressing slowly, making vertical, overlapping lanes over the abdominal cavity). No signs of hydronephrosis, abdominal aortic aneurism (AAA) or biliary complication were detected. Initial decompression was performed by placement of a nasogastric tube, which did not improve the comfort.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this critically ill patient, in whom SBO could not explain the severity of the symptoms and the lack of pain relief with therapy, the ultrasound was repeated using a linear probe (10–12<span class="elsevierStyleHsp" style=""></span>MHz), positioning it at the right midclavicular line at the level of the epigastrium, exploring the right hypochondrium and epigastrium, detecting two points at epigastrium (<a class="elsevierStyleCrossRef" href="#sec0065">Figure and video 1</a>) very similar to the “double lung point” seen in thoracic ultrasound.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> This “double gut point” is explained by the presence of air that is not free in the peritoneal cavity, and forms a bulla surrounded by adherent peritoneal layers.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Bowel ischemia leading to intestinal necrosis and perforation, in the setting of small bowel obstruction, was diagnosed on the basis of these results, confirmed later with abdominal CT.</p><p id="par0050" class="elsevierStylePara elsevierViewall">General surgery was consulted, who after assessing the high mortality risk of surgery, followed by family and patient consent, decided to start palliative care measures. The patient died 36<span class="elsevierStyleHsp" style=""></span>h later.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Acute abdominal pain is one of the most common complaints seen in the Emergency Department (ED), and it can be a life threatening if not early evaluated and correctly diagnosed. The increasing demand for a quality and timely emergency care, might increase the number of unnecessary investigations, such as plain abdominal radiography, leading to an overwhelming number of ionizing tests with normal results, waste of time and financial resources.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The definitive need of a computed tomography (CT) in complicated cases is undeniable, as management of many diseases is largely determined by CT findings as well as ruling out other differentials diagnosis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> However, CT scans cost more, take more time, require evaluation of kidney function, require contrast a lot of the times and expose patients to high doses of ionizing radiation.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The utility and scope of point-of-care ultrasound (POCUS) for evaluating and managing abdominal complaints in the ED has grown rapidly with little change in physician practice or patient awareness.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Despite its increasing availability in every ED, POCUS is underused in evaluating many common abdominal chief complaints in the ED.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> In 2012 the “Ultrasound First Forum” met and created the Ultrasound First Campaign<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> to encourage research and change practices in clinical situations where initial evaluation with POCUS may be safer, less costly and time consuming. Ultrasound First resulting in equivocal or indeterminate results would guide further imaging decisions. Therefore, ultrasound should be considered the first imaging study performed, particularly when the patient is hemodynamic unstable.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although POCUS is not meant to diagnose pneumoperitoneum, it can be detected during a focused study to rule-in other pathologies. When compared to X-ray, it showed a much higher sensitivity (93% versus 79%), accuracy (90% versus 77%), specificity (64% versus 64%), and positive predictive value (97% versus 96%).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In supine position, free air will tend to accumulate anterior over the liver and epigastrium. A curvilinear probe (2–3<span class="elsevierStyleHsp" style=""></span>MHz) can be used to initiate the abdominal POCUS examination, in the search of free fluid and rule-in causes of abdominal pain, but a second scan with a linear probe (10–12<span class="elsevierStyleHsp" style=""></span>MHz) can be more sensitive to detect signs such as the EPSS,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> which is the presence of air against the anterior abdominal wall, resulting in an enhancement of the peritoneum. Depth and gain are mainly determined by the patient body habitus. Consequently, switching probes should be part of our dynamic examination of the pneumoperitoneum.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In our case, it was possible to visualize 2 gut points (“double gut point”), which was found at epigastrium. This abdominal “double gut point” has not been previously labeled as such, being a novel sign to diagnose small amounts of free air in the peritoneal cavity (not only over the liver or epigastrium), and searching for this specific sign, in combination with the previously described, could aid to diagnose pneumoperitoneum.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Authors’ contributions</span><p id="par0085" class="elsevierStylePara elsevierViewall">All authors have contributed to this work. All authors read and approved the final manuscript.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethics approval</span><p id="par0090" class="elsevierStylePara elsevierViewall">A case report is a medical/educational activity that does not meet the definition of “research”, which is: “a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge.” Therefore, the activity <span class="elsevierStyleUnderline">does not</span> have to be reviewed by an IRB.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Consent to participate</span><p id="par0095" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient and/or family.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Consent for publication</span><p id="par0100" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient and/or family.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Availability of data and material</span><p id="par0105" class="elsevierStylePara elsevierViewall">Data available upon justifiable request to the correspondent author.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Code availability</span><p id="par0110" class="elsevierStylePara elsevierViewall">Not applicable.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">This work has not been supported by any public grants or other kind of financial support.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interest</span><p id="par0120" class="elsevierStylePara elsevierViewall">No sources of funding were used to assist in the preparation of this letter. The author certifies that he has no commercial associations that might pose a conflict of interest in connection with the submitted article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:17 [ 0 => array:3 [ "identificador" => "xres1910612" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1650044" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1910611" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1650045" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Ethics approval" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Consent to participate" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Consent for publication" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Availability of data and material" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Code availability" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 15 => array:2 [ "identificador" => "xack670369" "titulo" => "<span class="elsevierStyleBold">Acknowledgements</span>" ] 16 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-11-15" "fechaAceptado" => "2023-02-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1650044" "palabras" => array:5 [ 0 => "Pneumoperitoneum" 1 => "Ultrasound" 2 => "Intestinal perforation" 3 => "Point of care technology" 4 => "Case reports" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1650045" "palabras" => array:5 [ 0 => "Neumoperitoneo" 1 => "Ecografía" 2 => "Perforación intestinal" 3 => "Tecnología en el punto de atención" 4 => "Reporte de casos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pneumoperitoneum is a life-threatening condition, caused by hollow organ perforation. The diagnosis is often difficult, and Point-of-care ultrasound can be useful to distinguish from different conditions, and early set the indication of urgent surgery. We report on a critically ill patient, who presented to the Emergency Department with sudden increase in upper abdominal pain and distension with a diagnosis of small bowel obstruction on ultrasound using a curvilinear probe. After repeating the ultrasound using a linear probe, two dynamic points at mesogastrium very similar to the “double lung point” seen in thoracic ultrasound was detected. This “double gut point” due to bowel ischemia and perforation was confirmed on a computed tomography scan. In this case, the finding of an abdominal “double gut point” allowed us to diagnose localized pneumoperitoneum, being a novel sign, that could aid to diagnose small amounts of free air in the peritoneal cavity.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El neumoperitoneo es una afección potencialmente mortal causada por la perforación de un órgano hueco. El diagnóstico es a menudo difícil, y la ecografía en el punto de atención puede ser útil para distinguirlo de las diferentes opciones y establecer tempranamente la indicación de cirugía urgente. Presentamos el caso de un paciente en estado crítico que acudió al servicio de urgencias con un aumento repentino del dolor y la distensión abdominal superior, con el diagnóstico de obstrucción del intestino delgado en la ecografía realizada con una sonda cónvex. Tras repetir la ecografía con una sonda lineal se detectaron dos puntos dinámicos en el mesogastrio muy similares al «doble punto pulmón» visto en la ecografía torácica. Este «doble punto visceral», debido a la isquemia intestinal y a la perforación, se confirmó en una tomografía computarizada. En este caso, el hallazgo de un «doble punto visceral» abdominal nos permitió diagnosticar un neumoperitoneo localizado, siendo un signo novedoso no descrito anteriormente que podría ayudar a diagnosticar pequeñas cantidades de aire libre en la cavidad peritoneal.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0145" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0065" ] ] ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Figure and video 1." "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 593104 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Linear probe. Midline abdominal longitudinal view, showing a double gut point (asterisk), compatible with localized pneumoperitoneum. 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