What does this xray show and what is the diagnosis?
What is the differential diagnosis?
What operations can be done for the commonest condition giving this xray appearance?
This erect chest xray shows free gas under both diaphragms consistent with perforation of a hollow viscus. (See below for further details.)
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(See below for further details)
This is a chest x-ray taken in the erect posture showing gas under both domes of the diaphragm (pneumoperitoneum). This is diagnostic of perforation of a hollow viscus.
The commonest cause of pneumoperitoneum is peptic ulcer (duodenal) perforation. The differential diagnoses are:
perforated enteric ulcer of Peyer's patch (typhoid perforation).
perforated appendicitis.
perforated colonic cancer.
perforation of abdominal segment of oesophagus.
Other conditions which can cause pneumoperitoneum are:
following laparoscopy
tubal insufflation test
post-laparotomy patient
The operations which can be performed for a perforated duodenal ulcer are:
Primary closure of perforation over an omental patch.
Definitive treatment: This can be:
Primary closure of perforation over an omental patch followed by thorough peritoneal lavage; then a truncal vagotomy and posterior, retrocolic gastrojejunostomy is carried out.
In case of unscarred pylorus the perforation can be excised followed by a pyloroplasty; truncal vagotomy is then added after thorough peritoneal lavage.
Primary closure alone
Most of the patients can be treated by this operation and can be followed-up with anti-ulcer and H.pylori eradication treatment post-operatively. Majority of the patients are cured with this operation; a proportion of patients develop recurrence of symptoms. Nowadays some centres are closing a perforated duodenal ulcer laparoscopically.
Definitive surgery
Definitive surgery as an emergency is carried out only if the following criteria are satisfied:
youngish patient presenting with a prolonged history of dyspeptic symptoms prior to perforation
at surgery the ulcer is chronic with evidence of fibrosis and induration
minimal peritoneal contamination when the patient is operated within 4 hours of onset of symptoms
experienced team - surgical and anaesthetic
the condition of the patient should be stable to withstand a major procedure as compared to a simple closure alone.
