R gas under diaphragm

INTRODUCTION: The most common cause of gas under diaphragm is hollow viscous perforation. In 10% of cases it can be due to rare causes, both abdominal and extra-abdominal, one of them being intra abdominal infection by gas forming organisms. PRESENTATION OF THE CASE: A 51 year old male patient, a poorly controlled diabetic, presented with a second episode of severe pain abdomen and abdominal distention, with lower abdominal tenderness. Plain Xray of the abdomen in erect posture showed gas under the right dome of diaphragm and ultrasound abdomen confirmed gross pneumoperitoneum. On emergency laparotomy, a pancreatic abscess was discovered, which had ruptured through the inferior leaf of the transverse mesocolon. DISCUSSION: There are many obscure causes for extra-intestinal and extra abdominal sources for gas under diaphragm which contribute to 10% of the etiology for the same.These are as follows: post laparotomy status, ruptured liver abscess, retroperitoneal air, biliary-enteric fistula, gall stone ileus, incompetent sphincter of Oddi, focal biliary lipomatosis, post scuba diving, post adeno-tonsillectomy, post dental extraction, following arthroscopy of the knee, intra abdominal sepsis by gas forming organisms and pneumatosis coli to name a few. In this case, Klebsiella was responsible for producing gas under the diaphragm. CONCLUSION: Pancreatic abscess, in particular, as a extraintestinal source for gas under diaphragm has not been reported in English literature.