PMC6479146_01
Computed tomography. Images on lung window (A, B) demonstrate extensive pneumoretroperitoneum and free gas in the peritoneal cavity (arrow in A); gas penetrates abdominal wall muscles on both sides (arrows in B). A large diverticulum (C, asterisk) of the descending part of the duodenum was a cause of initial misdiagnosis of duodenal perforation; however, there is gas in an almost non-enhancing gallbladder wall (D) and in the pancreatic parenchyma consistent with emphysematous cholecystitis and pancreatitis (E)
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Based on the presence of free gas in the peritoneal cavity and retroperitoneally, mostly around the duodenum, pancreas, and visceral surface of the liver (Figure 1A), a radiologist on duty suggested a perforated duodenal diverticulum (Figure 1C), and a decision was made to perform an emergency surgery. Retrospective analysis of CT images revealed gas in the gallbladder wall and within pancreatic parenchyma (Figure 1D-E).