Intended for healthcare professionals

Endgames Picture Quiz

An elderly woman with chest pain and constipation

BMJ 2015; 350 doi: (Published 19 January 2015) Cite this as: BMJ 2015;350:h166
  1. Salomone Di Saverio, consultant general surgeon,
  2. Raffaele Lombardi, specialist general surgeon,
  3. Elisa Bianchi, surgical registrar,
  4. Gregorio Tugnoli, consultant general surgeon, head trauma surgery unit,
  5. Elio Jovine, head professor
  1. 1Local Health District, Bologna, Italy
  1. Correspondence to: S Di Saverio salo75{at}

An 89 year old woman with chronic obstructive pulmonary disease presented to the emergency department with worsening shortness of breath (87% oxygen saturation in room air), retrosternal chest pain, mild abdominal pain, and subacute partial bowel obstruction over the past six days. On physical examination she was dehydrated and she had tachycardia (105 beats/min), diffusely decreased breath sounds, audible crackles at the base of the right lung, and absent breath sounds on the left side pulmonary base. Her abdomen was distended but soft overall, the epigastrium and right hypochondium were slightly tender on deep palpation, and her rectum was empty. Her blood pressure was 130/85 mm Hg. Electrocardiography and troponin (measured at admittance and checked again after six and 12 hours) excluded myocardial infarction. Laboratory studies were unremarkable except for a mild microcytic anaemia (haemoglobin 115 g/L (reference range 120-160), mean cell volume 78.6 fL (80-96). Urgent chest radiography was requested (fig 1).


  • 1. On the basis of the radiograph and clinical findings, what is your differential diagnosis?

  • 2. How would you confirm the diagnosis?

  • 3. What complications may develop in a patient with this condition?

  • 4. What immediate management should be implemented?

  • 5. What definitive treatment options should be considered?

  • 6. What would you recommend to the patient after discharge?


1. On the basis of the radiograph and clinical findings, what is your differential diagnosis?

Short answer

The radiograph shows a large round shadow behind the heart with an air-fluid level. The right lung appears displaced and compressed. Differential diagnoses include cardiomegaly, huge pneumomediastinum and oesophageal perforation, epiphrenic oesophageal diverticulum, large pulmonary hydatid cyst, huge diaphragmatic hernia, delayed presentation of a large traumatic rupture of the diaphragm, paralysis of the left hemidiaphragm, mediastinal abscess, pulmonary tuberculosis, and gastrointestinal perforation with air migration above the diaphragm.

Long answer

The anterioposterior chest radiograph shows a large round shadow occupying the mid and left chest, with an air-fluid level …

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