abdominal perforation and decubitus view
A very interesting case report but a common omission seen again in this report as is seen in real life in the wards . Any x -ray for an acute abdomen should always include both the domes of diaphragm which I cannot see in the AP view in figure A (only left dome visible) as compared to B where both domes are clearly visible ( unless it was done originally but cut off in the view shown here in this report) which may lead to loss of very valuable sign of gas under the diaphragm . A decubitus film is a valuable view but if both domes of diaphragm specially the right are visible in an AP view , it could avoid a decubitus view specially in a very sick patient ( as in ventilated sick newborn babies ) where it may not be possible. A lateral 'shoot through' is done to diagnose perforation in such cases if needed, specially if the air leak is not a lot which can even easily disappear in a repeat x ray after few hours or at laparotomy. So the take home message is to always insist on complete view of both domes of diaphragm in an abdominal x ray for acute abdomen by clearly mentioning on the request form otherwise it does not happen ( as in this case reported ), resulting in repeat x rays or additional views on some occasions.
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