BMJ Case Reports 2018; doi:10.1136/bcr-2017-223081
  • Images in…

Beware of air

  1. David H T Tjan
  1. Department of Intensive Care Unit, Gelderse Vallei Hospital, Ede, The Netherlands
  1. Correspondence to Drs David H T Tjan, tjand{at}
  • Accepted 1 November 2017
  • Published 11 January 2018


We present three patients, treated at our intensive care unit (ICU), with radiological signs of free gas in different tissues.

Patient A, a 67-year-old man with a history of colitis ulcerosa, was admitted with acute right upper quadrant pain and fever. An abdominal X-ray (figure 1) showed free gas under the diaphragm and Rigler’s sign (indicating the presence of gas on both sides of the bowel wall).1 The CT scan revealed a toxic megacolon with signs of a pneumoperitoneum (figure 2) caused by a colon perforation.

Figure 1

Free gas in the abdominal cavity and Rigler’s sign (indicated by white arrows).

Figure 2

A toxic megacolon with signs of a pneumoperitoneum (indicated by red arrows).

Patient B, a healthy 62-year-old man, presented with malaise and substernal chest pain. During …

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