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Endgames Picture Quiz

Free air, but where?

BMJ 2013; 347 doi: (Published 08 October 2013) Cite this as: BMJ 2013;347:f5860
  1. P Morar, surgical registrar,
  2. J Hodgkinson, surgical senior house officer,
  3. H Hirji, radiology registrar,
  4. S Gould, consultant general and colorectal surgery
  1. 1North West London Hospitals NHS Trust, Department of Surgery, Northwick Park and St Marks Hospital, Middlesex HA1 3UJ, UK
  1. Correspondence to: J Hodgkinson jdh104{at}

A 62 year old fit and well Romanian man presented to our department with a two week history of worsening acute localised pain in the upper abdomen and vomiting. His surgical history included an open appendicectomy as a child and laparoscopic cholecystectomy 20 years ago. On presentation he had fever (39°C) and tachycardia (104 beats/min). His blood pressure was 125/73 mm Hg. He displayed generalised abdominal tenderness, worse in the right upper quadrant, with localised guarding in the right upper quadrant.

Blood tests showed a raised white cell count of 16×109/L (reference range 4-10×109/L) and a C reactive protein concentration of 277 mg/L (reference value <9 mg/L; 1 mg/L=9.25 nmol/L). A frontal projection erect chest radiograph was reported as showing pneumoperitoneum (fig 1).

Fig 1 Frontal projection erect chest radiograph


  • 1 What is the differential diagnosis given the clinical features only?

  • 2 What does the chest radiograph show?

  • 3 What features on the chest radiograph go against this being pneumoperitoneum? What are the alternative diagnoses?

  • 4 What is the next appropriate step in managing this patient?


1 What is the differential diagnosis given the clinical features only?

Short answer

The differential diagnoses include visceral perforation (gastric or duodenal) with abscess formation, biliary obstruction or cholangitis, acute pancreatitis, infective colitis, hepatic abscess, right lower lobar pneumonia, myocardial infarction, and gastritis.

Long answer

The differential diagnoses include any cause of acute intra-abdominal sepsis and localised peritonism. In association with upper abdominal signs, peptic ulcer disease is most likely (incidence 3.77-9.8/100 000).1 However perforated diverticulitis would be considered in patients of this age (incidence 3.9/100 000).2 Common biliary diseases such as …

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