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A 77‐year‐old man presented with epigastric pain and nausea that lasted for 36 h. On arrival, he was hypotensive (100/70 mm Hg) and had low‐grade fever (37.4°C). Physical examination showed generalised abdominal tenderness and a positive peritoneal sign. Plain abdominal radiography disclosed a double‐wall sign (arrows), indicating pneumoperitonium (fig 11).). Subsequent contrast‐enhanced computed tomography confirmed the presence of free air accumulation and extravasation of oral contrast medium in the peritoneal cavity. On exploratory laparotomy, a 1‐cm perforation above the prepyloric region was found. The patient underwent ulcerectomy and pyloroplasty, and had an uneventful recovery.
Double‐wall sign, also known as Rigler sign, indicates that both sides of the bowel wall can be visualised on a radiograph of the abdomen obtained with the patient in the supine position. The detection of pneumoperitonium by recognition of the double‐wall sign is important in patients with acute abdomen, as urgent surgical attention may be required.1
Competing interests: None.