Pneumoperitoneum — Causes and Management

The chest X-ray shown above demonstrates free air under both hemidiaphragms, a finding most consistent with which of the following diagnoses?

A 58-year-old man with a history of peptic ulcer disease presents to the emergency department with acute onset severe epigastric pain and abdominal rigidity. On examination, he is in distress with BP 100/65 mmHg, HR 110/min, and generalized abdominal guarding. Chest X-ray shows free air under the diaphragm. What is the most appropriate immediate management?

A 42-year-old woman undergoes elective laparoscopic cholecystectomy. Intraoperatively, the surgeon notes sudden loss of pneumoperitoneum and increased airway pressure. The patient's end-tidal CO₂ rises acutely to 65 mmHg. Trocar placement was in the left midclavicular line at the level of the umbilicus. What is the most likely complication and the immediate corrective action?

A 58-year-old man with a history of peptic ulcer disease presents to the emergency department with sudden-onset severe epigastric pain radiating to the back, followed by diffuse abdominal pain and rigidity. His vital signs show BP 95/60 mmHg, HR 118/min, RR 24/min, and temperature 37.2°C. Physical examination reveals a rigid, board-like abdomen with rebound tenderness and absent bowel sounds. Chest X-ray shows free gas under the right hemidiaphragm. What is the most appropriate immediate management?

A 58-year-old man with a 10-year history of peptic ulcer disease presents to the emergency department with sudden onset severe epigastric pain radiating to the right shoulder, followed by diffuse abdominal pain. On examination, he is in severe distress, BP 95/58 mmHg, HR 118/min, and the abdomen is rigid with generalized guarding and rebound tenderness. Chest X-ray (erect) shows a large crescent of air under the right hemidiaphragm. What is the most appropriate immediate management after fluid resuscitation and broad-spectrum antibiotics?