Question

2 X-rays (Erect & Supine) were given to identify the condition [Image shows erect and supine chest X-rays with air under diaphragm on erect view]

• A. Empyema Thorax
• B. Liver abscess
• C. Gastric volvulus
• D. Hollow viscus perforation

Hint:

Free gas under the diaphragm on an erect X-ray is pathognomonic of one specific emergency -- identify it correctly.

Answer 1

The Correct Option is D

Step 1: Interpret the X-ray findings. Two X-rays are provided: erect and supine abdominal/chest films. The key radiological sign visible on the erect film is air under the diaphragm (pneumoperitoneum) -- a crescent of free gas below the right hemidiaphragm. On the supine film, free intraperitoneal air may show as the Rigler's sign (both sides of the bowel wall outlined by gas).

Step 2: Clinical correlation. Pneumoperitoneum (free air under the diaphragm on erect CXR) is the hallmark radiological sign of hollow viscus perforation -- rupture of any hollow organ (stomach, duodenum, small bowel, large bowel) allowing intraluminal gas to escape into the peritoneal cavity.

Step 3: Rule out other options.

• Empyema Thorax: air-fluid level in the pleural cavity; not associated with subdiaphragmatic free gas.
• Liver abscess: may show gas within the liver parenchyma (on the right) but not free sub-diaphragmatic gas of the typical crescent pattern.
• Gastric volvulus: shows a massively distended stomach, often with two air-fluid levels; not the classic pneumoperitoneum picture.

Step 4: Conclusion. The erect and supine X-rays showing free air under the diaphragm are diagnostic of hollow viscus perforation.