A 42-year-old man presented to the emergency department with diffuse abdominal pain, confusion, and a history of fever and chills for the preceding 2 days. He was hypotensive and tachycardic. Abdominal examination revealed a soft, distended abdomen with moderate, diffuse tenderness to palpation, without rebound or guarding. Laboratory studies showed leukocytosis with a white blood cell count of 29 700/μL (reference range, 4500-10 500/μL; to convert to ×109/L, multiply by 0.001) and neutrophilia with a neutrophil count of 89.6%.
Upright chest radiography revealed pneumomediastinum, pneumopericardium, and a markedly distended stomach with air in the gastric wall (Figure 1). Abdominal computed tomography with intravenous and oral contrast revealed pneumoperitoneum, retroperitoneal gas, thickened gastric mucosa, and gas in the wall of the stomach (Figure 2).
Upright chest radiography demonstrates pneumomediastinum (thick arrow), pneumopericardium (short thin arrow), and air in the gastric wall (long thin arrow).
Computed tomographic scan demonstrates thickened gastric wall mucosa (thick arrow) with air within the gastric wall (thin arrow).
A. Ruptured pulmonary bleb
B. Gastric emphysema
C. Emphysematous gastritis
D. Perforated peptic ulcer
Schorn VJ, Baquerizo A, Mason RJ. Image of the Month—Quiz Case. Arch Surg. 2010;145(8):791. doi:10.1001/archsurg.2010.138-a