Right then left shoulder tip pain followed by generalised abdominal tenderness, maximal at the epigastrium. Associated melena and haematemesis. Hb drop from 120 to 67, pallor. Normotensive and normocardic. Past medical history included gastritis one month preceding, commenced on PPI.
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Erect chest radiograph demonstrating subdiaphragmatic free gas bilaterally and evidence of the cupola sign.
This case demonstrates pneumoperitioneum in a young patient with no known risk factors of peptic ulcer disease. The patient underwent urgent laparoscopy and was found to have a perforated gastric ulcer.