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A 72-year-old man presented to the emergency department with severe abdominal pain of two days' duration in the right lower quadrant. He reported recent use of nonsteroidal antiinflammatory drugs for a cold. His medical history was notable for previously treated Helicobacter pylori infection. An abdominal radiograph (Panel A) revealed air around the right kidney (arrows). Transabdominal ultrasonography showed that the right kidney was masked by air in the retroperitoneum, an artifact known as veiled right kidney sign. Abdominal computed tomography (Panel B) showed air surrounding the right kidney (arrows) and extending to the retroperitoneum. Thickening of the wall at the second and third portions of the duodenum was also noted. Endoscopy showed multiple gastric and duodenal ulcers. A duodenal ulcer with retroperitoneal perforation presenting with pain in the right lower quadrant (Valentino's syndrome) was diagnosed. The patient was treated with parenteral antibiotics without surgical intervention. His fever subsided in one day, and his recovery was uneventful.
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