PMC5724641_01
Erect plain chest radiograph demonstrating air beneath the right hemidiaphragm. However, there are also what appear to be haustra that contain the air, mimicking Chilaiditi's sign.
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There was the impression of air above the right liver on plain erect radiographs of the abdomen (Figure 1).
Intra-operative view of the right sub-diaphragmatic space during laparoscopic exploration in the same patient. There are well-developed diaphragmatic slips seen and corresponding hepatic grooves on the surface of the right liver (arrows). Free bilious fluid is also seen in the sub-diaphragmatic space.
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Inspection at the upper abdomen revealed the presence of hepatic surface grooves and associated diaphragmatic slips (Figure 2).
Laparoscopic exploration has revealed a perforated peptic ulcer as the source of contamination and a true pneumoperitoneum.
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Further inspection revealed that the source of contamination was free perforation of a peptic ulcer at the first part of the duodenum (Figure 3).