Large volume subdiaphragmatic pneumoperitoneum. The lungs and pleural spaces are clear. No pneumomediastinum or pneumothorax. Normal heart and cardiomediastinal contours allow for AP projection. No rib fracture was identified.

Severe tension pneumoperitoneum with large volume of free intraperitoneal gas causing mass effect with significant abdominal distension and posterior displacement and compression of the abdominal viscera and bowel loops. Of note, numerous scattered free gas locules are identified adjacent to the distal esophagus, gastro-esophageal junction, and adjacent to the gastric fundus. In this region, a linear lucency is observed traversing the posteromedial wall of the gastric fundus/superior lesser curvature, which communicates with a large pocket of intraperitoneal free gas lateral to the left diaphragmatic crus, suggestive of a site of gastric wall rupture, located approximately at the level of the inferior T11 vertebral body on the axial CT.

An air-fluid level is observed in the stomach, with the majority of the stomach and duodenal bulb distended with gas. The second and third segments of the duodenum appear collapsed. Small bowel loops are diffusely distended with gas, with a maximal caliber of 33 mm. No definite site of duodenal or small bowel perforation is identified on CT. The large bowel is faecally loaded throughout its length, but otherwise demonstrate normal wall enhancement and caliber. No pneumatosis intestinalis or portal venous gas. No free extraperitoneal or retroperitoneal gas or collection.

Evidence of pneumobilia extending into the right and left hepatic ducts. Liver parenchyma appears otherwisezz normal for portal venous phase imaging. The main portal vein and its intrahepatic branches are patent, although the portosplenic confluence, SMV and its tributaries are flattened secondary to compression. The pancreas, spleen, adrenal glands, kidneys, and ureters are unremarkable in appearance.

The IVC is collapsed, likely secondary to compression, concerning for compromised hemodynamics due to potential reduction in venous return to the heart.

Normal appearance of the abdominal aorta, with background atheromatous disease and intermittent atherosclerotic wall calcifications. An acentric hypoattenuating crescent shaped filling defect of the SMA extending 18 mm inferiorly from the level of the L2-3 intervertebral disc may represent a short segment dissection. Distal to this segment, the SMA opacifies normally on non-dedicated imaging. The celiac axis and its branches, the renal arteries and IMA opacify normally. No evidence of pseudoaneurysm, aneurysm or other arterial dissection.

Alignment of the imaged thoracolumbar sacral spine is within normal limits. No destructive osseous lesions identified. Centrilobular and paraseptal emphysematous changes appreciated within the imaged portion of the lungs within the limitations of motion artefact.

Impression

1. Severe tension pneumoperitoneum causing significant mass effect and displacement of intraabdominal viscera, with a potential site of gastric wall rupture at the lesser curvature as described above. Note is made of a collapsed IVC, concerning for impaired venous return.

2. An 18 mm long eccentric hypodensity within the right lateral wall of the SMA consistent with atheromatous disease.