Radiology – Case 1
An 41 year-old male presented to the emergency department with the sudden onset of severe epigastric pain. He had a history of heart burn and dyspeptic symptoms for past 10 years. On physical exam, he had a temperature of 101.4°F, a pulse of 118 and a blood pressure of 128/72. Abdomen was tender with board like rigidity. An X-ray was taken to confirm the diagnosis.
What is the diagnosis revealed in the X-ray given above? What are the other conditions that can produce this sign?
Answer:
X-ray shows gas under diaphragm – pneumoperitoneum. From the history and the X-ray findings, this is probably a case of perforated peptic ulcer.
Causes of gas under diaphragm are:
- Perforated peptic ulcer
- Small bowel perforation
- Ruptured diverticulum
- Penetrating injury to bowel
- Necrotising enterocolitis/Pneumatosis coli
- Bowel malignancy
- Ischemic bowel
- Steroids
- After laparotomy / laparoscopy
- Breakdown of a surgical anastomosis
- Peritoneal dialysis
- Vaginal insufflation (air enters via the fallopian tubes as in tube patency testing)
- Colonic or peritoneal infection
- From chest (e.g. bronchopleural fistula)
- Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea
Differential diagnosis of gas under diaphragm:
- Subphrenic abscess
- Chilaiditi syndrome – bowel interposed between diaphragm and liver
- Atelectasis at lung base
Image credit : Clinical_Cases (wikipedia)
15 Comments
from x-ray it is evident that there is free gaS under diphragm…..which due to rupture of hollow visera in abdomen…..
my diagnosis is peptic perforation …as there is history of heart burn and dyspeptic symptom for last 10 years
pleural effusion
it’s a c/o peptic ulcer perforation associatd with peritonitis.air under the diaphragm.also seen in conditions like after intra abdominal surgery,tubal insufflation..
perforation
its the case of perforated esophagous…showing air below the diaphragm
can also found in perforated typhoid ulcer
this is a case of perforated gastric/peptic ulcer….
D/D are—
1) Boerhaave’s syndrome (esophageal tear) – rare cause
2) Perforated peptic ulcer (stomach or duodenum) – common
3) Perforated gastric cancer – less common
4) Spontaneous perforation of the small intestine – rare
4) Perforated diverticulitis of the colon – common
5) Perforated colon cancer – common
6) Abdominal trauma
perforation peritonitis d/t peptic ulcer….gas under diaphragm..pneumoperitoneum other causes are..
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g. megacolon)
Necrotising enterocolitis/Pneumatosis coli[2]
Bowel Cancer
Ischemic bowel
Steroids
After laparotomy
After laparoscopy
Breakdown of a surgical anastomosis
Bowel injury after endoscopy
Peritoneal dialysis
Vaginal insufflation (air enters via the fallopian tubes, e.g. water-skiing, oral sex)
Colonic or peritoneal infection
From chest (e.g. bronchopleural fistula)
Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea.
diagnosis : B/L air under diaphragm due to rupture/perforation of hollow viscus along with ? cardimegaly
perforation is the cause here secondary due to chronic gastric ulcer
need emergency lapratomy.
Perforation peritonitis
PG BLAZER is doing a nice job.this is a case of peptic ulcer perforation,as evidenced by chest xray as a free air under diaphragm..and with clinical findings…patient was having symptoms such as burning sensation and dyspepsia,whih point towards peptic ulcer.many conditions cause this…………….
Pneum0peritoneum due 2 peptic ulcer perf0rati0n
Acute pancraetitis
the xray shows air under the diaphragm it is a case of perforation hollow viscus air under under the diaphragm main cause is perforated duodenal ulcer other causes are trauma.
this is a case of peptic perforation.other D/D-1.aspiration pneumonia follow prolong vomiting in intestinal obstruction.2.plural effusion(Lt)complicates acute pancreatitis.
perforation leading to peritonitis…