Introduction: A patient with chest contusion and rib fractures presented with severe chest pain. The plain film of his chest showed suspicion of pneumoperitoneum. We present this case to show how to get a correct diagnosis and then avoid unnecessary surgery.
Case presentation: A 64-year-old Taiwanese man presented to the emergency department complaining of severe right chest pain after a traffic accident. Chest radiography showed right fifth to eighth rib fractures and was suspicious for free air under the bilateral hemi-diaphragm. Computed tomography of the abdomen revealed interposition of bowel loops between the liver and diaphragm. The patient was treated with oral analgesics and then regularly followed in the outpatient department.
Conclusion: Awareness of Chilaiditi's sign is of paramount importance when free air under the diaphragm is seen in a patient (particularly an older patient) who does not exhibit signs of peritoneal irritation on physical examination. Emergent laparotomy should be delayed and a computed tomography scan should be done first. No inappropriate surgical intervention is needed.