Quiz: Acute Abdomen with UGIB

This 33 years old lady presented with vomiting out blood, passing out blackish discoloration of the stool and abdominal pain.

This is her erect chest X ray film. Explained your finding and possible diagnosis

Answer

The chest X ray erect film shows gas under the left diaphragm and the diagnosis is perforated gastric ulcer.

Note: laparotomy was done in this patient and noted finding of large PGU but still managed to be repaired with Graham's patches

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Image of the Day 18: Perforated Viscus [Link]

Chest X Ray: Air Under Diaphragm [Link]

 

Chest X Ray: Air Under Diaphragm

Gas under diaphragm is synonym with pneumoperitoneum which could be due to many reason. Most of it are due to perforated viscus. Apart from that, other condition may also occurs. Therefore, correct history taking and good physical examination may aid in making a diagnosis.

Differential diagnosis for gas under diaphragm includes.

1) Perforated viscus.

a) GI Malignancies

b) Perforated ulceration of GI Tract

c) Typhoid

d) Tuberculosis

e) Ulcerative Colitis

f) Foreign body

g) Inflammation

h) Diverticulum

1) Trauma

j) Intestinal obstruction

2) Subphrenic abscess with gas

3) Intra abdominal abscess with gas forming organism.

4) Transposition of viscera

eg Chilaiditi syndrome (Interposition of the colon and the liver below the right hemidiaphragm.

5) Spontaneus pneumoperitoneum

6) Idiopathic pneumoperitoneum

7) Pneumatosis cystoides intestinalis (gas cyst of the intestine. a very rare entity usually associated with cararrhal enteritis)

8) Transposition of gas from pneumothorax or lung bullae