Epigastric pain, vomiting, constipation, abdominal distension for two days.
Erect AP abdominal radiograph
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Significant amount of crescentic free air is visible under both hemidiaphragms. Furthermore an air-fluid level is visible on the right (see key image), highly suggestive of abdominal free fluid (confirmed by US). Distended loops of small bowel are also visible in the left upper quadrant with characteristic double wall (Rigler)-sign in the region containing free extraluminal air (key image). The stomach is also distended.
The findings are in line with pneumoperitoneum caused by bowel perforation, consequent adynamic ileus and buildup of free fluid. The patient was admitted for surgery, which confirmed perforation of the pyloric part of the duodenum complicated by peritonitis.