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Hungarian Radiology

SEPTEMBER 20, 2008

[The bubble-sign of spontaneous pneumoperitoneum]

SZÁNTÓ Dezső

[INTRODUCTION - Pneumoperitoneum is a reliable indicator of serious underlying damage. There are four etiologic categories of extraluminal-intraperitoneal gas collections: spontaneous, iatrogenic, traumatic and criminal perforations. The erect posteroanterior chest radiograph is the most sensitive plain film projection for detecting pneumoperitoneum and it may show 0.5-1 ml free abdominal gas when meticulous radiographic techniques (lateral, oblique, air-gap, lordotic, inspiratory and expiratory exposures) are used. The appearances of extraluminal gas collections are specified by physical rules and individual preferences. The bubble-sign is an uncommon, pathognomonic phenomenon. CASE REPORT - A case of an 86 years old female patient with spontaneous pneumoperitoneum, diagnosed on the basis of the bubble-sign is presented. On erect, lordotic inspiratory chest film, right medial inversion of diaphragm, left pleural effusion, emphysema, cardiomegaly and aortectasia were observed. The bubble-sign and hydromediastinum became evident in the right phrenicocostal angle on expiratory view. Our patient expired before the surgical intervention.The postmortem demonstrated double peptic duodenal ulcers; the older ulcer had penetrated and encapsulated in the hepatoduodenal ligament, while the more recent one perforated through the intraperitoneal space. CONCLUSION - Routine upright chest films are valuable screening tools for uncommon signs of pneumoperitoneum, also.]