The patient was presented to the ER with acute upper abdominal pain. Erect frontal radiograph of the abdomen revealed mild amount of pneumoperitoneum. The possibility of perforated bowel was raised and further evaluation with CT was requested.

The patient received positive oral contrast through a nasogastric tube and the obtained routine axial cuts showed a possible perforation at the anterosuperior aspect of the first part of the duodenum. The axial cuts were then retaken in a prone position which showed minimal extraluminal contrast leak at the suggested site of perforation.

The patient was sent to OR and a duodenal perforation was confirmed.