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A 56-year-old man presented to the emergency department with a 3-day history of diarrhea and dull epigastric pain. The diarrhea had responded to antidiarrheal agents. However, the epigastric pain had worsened on the day before presentation and had become sharp, severe, and diffuse. The patient reported having had no bloody or tarry stool and having taken no nonsteroidal antiinflammatory drugs. On physical examination, the patient appeared to be in great distress and was tachycardic, with otherwise normal vital signs. His abdomen was diffusely tender with rebound; bowel sounds were absent. The rectal examination revealed occult blood. Laboratory evaluation showed leukocytosis, with a white-cell count of 20,400 per cubic millimeter and 82% segmented neutrophils. No anemia was found. Supine plain radiography of the abdomen revealed a small triangular pocket of air outlined by three adjacent bowel loops (Panel A, arrow), a finding that was consistent with the presence of free intraperitoneal air; this is known as the telltale triangle sign. Abdominal computed tomography confirmed the presence of pneumoperitoneum (Panel B, arrowheads) and also showed a subdiaphragmatic abscess with an air–fluid level (Panel B, arrow). During surgery, a perforated gastric ulcer and two intraabdominal abscesses were found. The patient underwent ulcerectomy with pyloroplasty and drainage of the abscesses; he also received a proton-pump inhibitor. The patient was doing well at follow-up 6 months after surgery.
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