Pneumoperitoneum

Case contributed by J Yeung
Diagnosis certain

Presentation

Acute abdominal pain

Patient Data

Age: Elderly
Gender: Female

Abdominal x-ray

x-ray

Numerous small bowel loops outlined by gas both within the lumen and free within the peritoneal cavity. There is also ascites, with mottled gas densities over bilateral paracolic gutters.

Annotated

Annotated image

In a normal x-ray, only the luminal surface (blue arrows) should be visible outlined by gas. The serosal surface (orange) should not be visible as it is normally in contact with other intra-abdominal content of similar density (other loops of bowel, omentum, fluid). In this case, gas abuts the serosal surface rendering it visible. 

As this film has been obtained supine (note absence of air-fluid levels), ascites pools in the paracolic gutters, with fluid mixed in with gas bubbles (green arrows). 

Case Discussion

Radiographic features of pneumoperitoneum include

This patient underwent an emergency operation. Findings included large amount of feculent fluid within the peritoneum causing peritonitis. The underlying cause was the rupture of jejunal diverticula.

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