Case contributed by Dr Prat-Matifoll


73 year old patient suffering from cirrhosis and ascites, referred diffuse abdominal pain.

Patient Data

Age: 73
Gender: Female

Note how well delineated is the abdominal wall in both flanks as well as left psoas, this could raise the suspicion of perforation even in an upright abdominal x-ray. 

A chest x-ray was performed to rule out the presence of extraluminal gas in the subdiaphragmatic domes. No free gas was visualized in this area.


Note the presence of bilateral urinary tract Double J stent. After performing an abdominal sonography to rule out acute complications related to cirrhosis, an unexpected bilateral ureterohydronephrosis was observed. CT showed multiple metastasic lesions in bones, peritoneum and periureteral implants as a probable cause for a sudden increase of ascites and bilateral ureterohydronephrosis. The primary cancer was a breast cancer.


Case Discussion

These findings remark the importance of detecting typical findings of pneumoperitoneum and his differential diagnosis with pseudopneumoperitoneum (basal linear atelectasis
pneumomediastinum, Chilaiditi syndrome, diaphragmatic undulation, gas within skin folds, biliary, portal vein or bowel wall gas, fat within the subdiaphragmatic space or the ligamentum teres, properitoneal fat stripe).

Remember, an erect chest x-ray is the most sensitive plain radiograph for the detection of free intraperitoneal gas.

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Case information

rID: 43732
Published: 23rd Mar 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Excluded

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