An elderly gentleman suddenly developed moderate to severe epigastric pain associated with hypotension and tachycardia. A supine abdominal X-ray was taken. Urgent CT abdomen performed after initial stabilisation revealed large amounts of free gas and fluid in the peritoneal cavity. Emergency Laparotomy revealed a perforated gastric ulcer. Review of the supine abdominal X-ray showed a number of radiological signs of pneumoperitoneum. As supine abdominal X-rays are commonly performed in emergency departments, doctors should be competent in interpreting the radiological signs.
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