Presentation
Sudden onset of severe abdominal pain, with vomiting, hypotension and a completely rigid abdomen with percussion tenderness.
Patient Data
Abdomen ultrasound
There is free gas seen as lines on the liver surface with comet-tail artifacts (yellow arrow). Perforated ulcer in anterior duodenal bulb is associated.
Abdominal radiograph
The left lateral decubitus position shows a small amount of intraperitoneal free gas.
CT Abdomen with contrast
Evidence of considerable amount of free gas over the surface of the right and left lobes of the liver with fluid collections within the hepatorenal recess and in the rectovesical pouch. There is thickening of the first and second parts of duodenum with a localized perforation of a duodenal ulcer along its bulb on the anterior wall (red circle). Near the perforation there is a little fluid collection. There is a cyst in the left hepatic lobe.
Perforated duodenal ulcer repair and omentoplasty (summary translated from Italian).
Case Discussion
Ultrasound of intraperitoneal free gas appears as an enhanced peritoneal stripe accompanied by posterior artifactual reverberation echoes with characteristic comet-tail appearance. Right upper quadrant and midline are the best regions to detect intraperitoneal free gas.
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