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Case of the Month 08/06

68 year old female presents with abdominal pain x 1 week, severe in the past 24 hours. She has had years of LLQ pain, she says, for which she takes ASA. One week ago her LLQ pain began to worsen but still was waxing and waning. Yesterday evening, the pain began to be throughout her abdomen and her right back.

Q: What's wrong with this picture?

View answer

There is free air or pneumoperitoneum.

Q: Where is the best place to look for this on abdominal CT?

View answer

Since the image is taken when the patient is supine, air will be seen just posterior to the anterior abdominal wall and overlying the ventral surface of the liver.

Q: Which window setting on the view box may make seeing this diagnosis easier?

View answer

This case is not subtle, but if it were, viewing the images using lung windows (as done here) would make the air pockets more obvious.

Conclusion

This patient went to the OR the same evening and was found to have a 5 mm ulcer in the first portion of the duodenum. It was repaired and she was discharged from the hospital in 1 week.

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