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?
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
- 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
- Subphrenic abscess
- Chilaiditi syndrome – bowel interposed between diaphragm and liver
- Atelectasis at lung base
Image credit : Clinical_Cases (wikipedia)