A 3 month old male with a history of ileostomy s/p revision, left inguinal hernia s/p repair, and incisional hernia presents to the ED with abdominal distension and vomiting.  He is febrile and irritable.  A plain abdominal xray is shown below.  What's the diagnosis?  Scroll down for answer.

Answer:  Perforated viscus

• X-ray shows intraperitoneal free air -  this case demonstrates the the importance of 2 views as free air notable tracking on the right side of abdomen with left side is down
• Management involves stat surgical consultation, broad spectrum antibiotics including anaerobic coverage, and fluid resuscitation