A 68-year-old male with a history of heavy NSAID use presents with sudden onset of agonizing, diffuse epigastric pain that started 2 hours ago. On examination, his abdomen is rigid and 'board-like' with involuntary guarding. What imaging study is the fastest initial test to identify pneumoperitoneum?

Answer and explanation

Correct answer: D. Erect chest radiograph including diaphragms

  1. Step 1: Sudden severe abdominal pain with a board-like rigid abdomen strongly suggests a perforated viscus, most commonly a perforated peptic ulcer.
  2. Step 2: An erect chest radiograph allows free intra-abdominal gas to rise under the diaphragm (subdiaphragmatic free air / pneumoperitoneum) in 75-80% of cases.
  3. Step 3: Barium contrast is strictly contraindicated in suspected perforation due to chemical peritonitis.
Answer
Erect chest radiograph including diaphragms.
Why not the others: 'Supine pelvic radiograph' cannot demonstrate free subdiaphragmatic air as gas disperses anteriorly; 'Abdominal ultrasound of the gallbladder' is insensitive for diffuse free intraperitoneal gas; 'Barium swallow examination' is contraindicated because extravasated barium produces severe chemical peritonitis and mediastinitis.

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