A 53 yo female presents with acute onset of sharp abdominal pain.  She is rolling back and forth on the stretcher, visibly in pain.  She has tachycardia, but otherwise her vitals are normal.  A stat portable x-ray is shown below.  What's the diagnosis? (scroll down for answer)

Answer:  pneumoperitoneum

• Requires emergent surgical consultation and broad spectrum antibiotics to cover enteric organisms; metronidazole or a carbapenem may be added to the traditional two-antibiotic regimen
• In rare cases abdominal compartment syndrome may ensue if the perforation acts as a one-way valve creating a tension pneumoperitoneum
• Click here for additional images of pneumoperitoneum