16 yrs old female with high grade fever with distension of abdomen with one week history presented in emergency department.Hb 5.6mg/dl and TLC 8500.following r the X Ray images. What likely diagnosis.

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Fever 1 week with distention of abdomen X-ray showing free gas under Rt dome of diaphragm. Bowel perforation ? Eneric Sub cutaneous has in thigh ? Gas gangrene

Gas shadow under both hemidiaphragm...(chilaiditi syndrome)... with increase abd gas.... intestinal obstruction? with perforation...

Sorry I did not see the third x ray lt shows gas shadows inmuscle plane . one has to think of gas gangrene and some times necrotising fascitis.

Gas under both dom of diaphragm suggestive of perforationwith gas gangrene in last xray..

3 rd x Ray suggests possible gas gangrene

3 rd x ray showing gas could have tract down from retroperitoneal plane to thigh .many time it is seen in perforated colonic diverticuli or emphysematous pyelonepharitis

Bacterial purulent peritonitis after abdominal in flammed organ ie appendix or diverticulum causing subphrenic abcess.

Emphysema of thigh in this may be due to enterocutaeneos fistula . If threre are signs of inflammatiin in thigh it suggest necrotising fascitis.

Pneumoperitonium with subcutaneous gas thigh.

Gas is present under the dome and the lateral abdominal wall. Along with the third x-ray I feel has gangrene is more likely. Detention could be coz if that. Prognosis is poor,AGS should be given and conserved. Surgical intervention might not be of much help. However I would be interested to know what the senior surgeons might suggest.

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