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?


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)


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