A 65 year-old man complained of suddent onset of chest pain
He had past history of left pneumonectomy for carcinoma of lung 5 years ago. He complained of acute onset of lower central chest pain for one day. ECG showed reversible ischemic change over the inferolateral leads. While he was treated as acute coronary syndrome, his abdominal pain improved on first day. On the second day of admission, he suffered from return of abdominal pain. He became more septic and was more breathless. As CT abdomen was not immediately available at that moment, the on-call surgeon had to decide whether there was enough grounds to arrange emergency laparotomy on this vulnerable and weak patient without a CT scan.
What sign is shown here?
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This patient had massive pneumoperitoneum as shown by the “double-wall” sign of intestine, or the classical Rigler’s sign. The magnifying version and the sign are outline by arrow
However, Rigler ‘s sign is poorly sensitive to detect free gas in peritoneal cavity. At least 1 L of free gas has to be present before this sign is shown up. Decubitus film may help better if CT is not immediately avaiable
The surgeons decided to perform laparotomy for this gentlemen. A huge perforation at first part of duodenum causing badly contaminated peritoneum was detected, and a partial gastrectomy + controlled duodenostomy was done. He recovered fairly well after 5 days of stay in ICU.