Perforated peptic ulcer detected by ultrasonography with air insufflation

Pneumoperitoneum on an erect chest radiograph is essential for the diagnosis of hollow organ perforation. Preoperative detection of a perforated peptic ulcer (PPU) is crucial for precluding unnecessary invasive diagnostic procedures; however, free air cannot be detected on radiographs in 30% of patients with a PPU. We present the case of a 57-year-old man with decompensated cirrhosis of the liver who suffered from acute abdominal pain during his admission to the hospital. Real-time ultrasonography with air insufflation via a nasogastric tube revealed free air in the patient's peritoneal cavity, and hyperechoic bubbles that were flowing through a perforated tract at the posterior wall of the pylorus.