PSPal Surgery

Station 1 of 6Acute abdomenErect abdominal X-ray5 minutes

Imaging station 1

Read the stem, open the images, and answer each question aloud before you reveal the model answer.

The stem

A 30-year-old man presents with one day of abdominal pain. He has no vomiting, diarrhoea or urinary symptoms. His abdomen is soft, with mild tenderness. An erect abdominal radiograph is taken.

Erect abdominal X-rayImages on Radiopaedia
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Case courtesy of Mohammad Osama Hussein Yonso, Radiopaedia.org. View the case. Licensed CC BY-NC-SA 3.0.

The examiner’s questions

Question 1Describe the main abnormality.Show the model answer
Free intraperitoneal gas beneath both domes of the diaphragm: a pneumoperitoneum.
Question 2What is the most likely cause, and what else can cause this appearance?Show the model answer
A perforated peptic ulcer, gastric or duodenal, is the most likely cause. Others include a perforated diverticulum or appendix, perforated bowel cancer, and recent abdominal surgery or laparoscopy, after which free gas is expected for some days.
Question 3Which plain film is best for detecting free gas, and how should it be taken?Show the model answer
An erect chest X-ray, taken after the patient has been sitting upright for about ten minutes so the gas can rise. If the patient cannot sit up, a left lateral decubitus film is used. CT is the most sensitive test.
Question 4What is your initial management?Show the model answer
Resuscitation: nil by mouth, intravenous fluids, analgesia, nasogastric tube and urinary catheter. Bloods including amylase, group and save. Intravenous antibiotics and a proton pump inhibitor. Urgent senior surgical review for operative repair.
After you answerThe teaching pointShow

This patient had only mild tenderness. Free gas means a perforation until proved otherwise, however reassuring the abdomen feels, unless there has been recent surgery.

Related: The acute abdomen →

Source case on Radiopaedia: “Pneumoperitoneum”, by Mohammad Osama Hussein Yonso.

ContentsAll 6 stationsNextStation 2 · Abdominal imaging

This station page is shared under CC BY-NC-SA 3.0, the licence of the Radiopaedia case it uses.