Winner of the Clinical Quiz Dr. Deepa John Thomas, Assistant Professor Department of Pediatrics, Mount Zion Medical College, Kerela.Question 1: What is depicted by white arrows in Image 3? Name the sign depicted by green arrows in the same imageImage 3: Erect X-ray abdomenAnswer: White arrows in Image 3 depict free air below the diaphragm in erect position. Green arrows represent continuous diaphragm sign which is due to the outline of diaphragm in entirety by the free air in abdomen. Question 2: What is the classical sign depicted in Image 4 by white arrows? Green arrow, blue arrows, and red arrows represent which named signs, respectively, and represent which intra-abdominal structures?Image 4: Supine X-ray abdomenAnswer: The classical sign depicted by white arrows in Image 4 in the X-ray abdomen is football sign,1 which is due to the accumulation of free air below the anterior abdominal wall in supine position. Green arrow represents the falciform ligament sign or silver sign which is due to the outline of falciform ligament by free air in the abdomen. Inverted V sign or lateral umbilical ligament sign is represented by red arrows which are due to the outline of lateral umbilical ligament by free air in the abdomen. Blue arrow represents the Rigler sign or double bowel sign in which both sides of bowel/stomach becomes visible. Inner side becomes visible due to gas present inside the bowel and outer wall becomes visible due to free gas in the peritoneal cavity. Question 3: What is the clinical diagnosis as per Images 3 and 4? Answer: Clinically, the findings indicate massive pneumoperitoneum with free air in the peritoneum visible as black halo around the abdominal contents. Question 4: What is the further line of management in such a case? What can be the possible causes of the same in this case? Answer: Emergency exploratory laparotomy should be performed in such a case of massive and progressive pneumoperitoneum.2 In cases with minimal free air in the abdomen in a hemodynamically stable neonate with no evidence of peritonitis, leukocytosis, or sepsis, conservative management has been tried with strict monitoring of abdominal girth, per abdominal examination, and blood investigations. Exploratory laparotomy should be performed in case of any evidence of sepsis, necrotizing enterocolitis, or peritonitis. Possible causes in this case include intestinal or gastric perforation either spontaneous (without any evident cause) or due to intestinal obstruction or gut ischemia. The relatively early presentation in the index case goes against the diagnosis of necrotizing enterocolitis, which is usually the cause of intestinal perforation and pneumoperitoneum in preterm neonates. The index case was taken up for right upper quadrant transverse laparotomy and neonate was noted to have proximal ileal perforation which was closed. The remaining small bowel, stomach, and colon were healthy and a clinical diagnosis of spontaneous intestinal perforation was made.3Comments by Dr. Ankita Patel (Section Editor) The quiz underscored the significance of recognizing classical radiological signs and understanding their anatomical correlates, which are critical for timely diagnosis and appropriate surgical decision-making. We are happy to see consistent interest among pediatricians in this section and glad to have Dr. Deepa as winner for the second time. We warmly encourage more readers to participate in upcoming quizzes which enrich learning and promotes meaningful academic exchange.Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Sasikumar et al. (Thu,) studied this question.