Annals of Medicine and Surgery 3 (2014) 111e112 Contents lists available at ScienceDirect Annals of Medicine and Surgery journal homepage: www.annalsjournal.com Grand round A 50 year old man with acute abdominal pain * Sukhpreet Singh Dubb a, Joanna M. Farrant b, B.V. Praveen c, Sascha Miles-Dua c, a Broomfield Hospital, Essex, United Kingdom b Imperial College London, United Kingdom c Southend Hospital, Essex, United Kingdom article info Article history: beats per minute. He has generalised tenderness of the abdomen, Received 25 June 2014 guarding and absent bowel sounds. This is his abdominal x ray. Accepted 26 June 2014 What is the most likely diagnosis? Keywords: A Perforated sigmoid diverticulae Acute abdominal pain B Perforated peptic ulcer CXR Perforated peptic ulcer C Spontaneous bacterial peritonitis The correct answer is B. The most likely cause of the pneumoperitoneum is a perforated peptic ulcer. This patient has a history of indigestion and takes regular anti inflammatory drugs. The supine x-ray of the abdomen You see a fifty year old man in the emergency department. He has shows normal gas in the bowel and free air outside of the bowel. had worsening abdominal pain for the last twenty four hours. He has This is known as Rigler's sign. arthritis and takes regular anti inflammatory drugs. He tells you that Rigler's sign is usually seen when there is more than one the tablets cause indigestion but that he needs to take them for the thousand mls of free gas and fluid in the peritoneum. There is also a arthritis. On examination he is lying very still. His heart rate is 120 pocket of air in the right iliac fossa between the loops of bowel. This is why the following answers are incorrect. A. There is no history of diverticular disease in this patient. This patient has a history of indigestion and takes regular anti inflam- matory drugs. The most likely cause is a perforated peptic ulcer. C. Free intraperitoneal gas is the striking feature on this X-ray, which is not characteristic of spontaneous bacterial peritonitis. 1. Learning bite The most common cause of pneumoperitoneum is iatrogenic e Recent surgery (In most patients post surgical pneumo- peritoneum resolves with one week)or instrumentation such as insertion of a paracentesis drain Trauma Leaking surgical anastomosis Thoracocentesis/erroneous chest drain insertion Following this the most common cause is perforated abdominal Fig. 7. A Supine X ray of the abdomen. viscus usually perforated peptic ulcer (gastric or duodenal) Other causes of pneumoperitoneum include a perforated sigmoid diver- ticulum (Nawaz Khan et al.). * Corresponding author. Broomfield Hospital, 1 Court Road, Chelmsford, Essex CM17ET, United Kingdom. Tel.: þ44 (0) 1245443673. E-mail addresses: [email protected], [email protected] (S. Miles-Dua). Infection of the peritoneal cavity with gas forming organisms http://dx.doi.org/10.1016/j.amsu.2014.06.012 2049-0801/© 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd. 112 Grand round / Annals of Medicine and Surgery 3 (2014) 111e112 2. Clinical tip Colonic interposition between the superior surface of the liver and the diaphragm e known as Chilaiditi syndrome Other signs associated with pneumoperitoneum include: Basal lung bulla Subphrenic abscess caused by gas forming organisms Air under the diaphragm e this is seen in seventy five Cysts of pneumatosis coli and percent of patients with a perforated peptic ulcer (Khan Basal atelectasis et al.) [1] Lucency that outlines the falciform ligament in the right upper Reference quadrant Sharp demarcation of the intraperitoneal organs e such as the [1] Ali Nawaz Khan. http://emedicine.medscape.com/article/ liver, gall bladder and spleen and 372053-overview. A round area that is lucent in the mid abdomen e this is com- mon in children You should be aware that it is possible to incorrectly diagnose pneumoperitoneum inpatients with other conditions. These include:.