The presence of extraluminal air in an acutely ill patient with abdominal pain is an ominous sign that usually indicates perforation of a hollow viscus. Common causes include gastroduodenal peptic ulcer disease, perforation of a gastrointestinal neoplasm, acute appendicitis with perforation, and acute colonic or (less often) small bowel diverticulitis, including Meckel's diverticulitis.[1] Other considerations include iatrogenic perforations caused by catheters or endoscopes, perforations caused by foreign bodies, or spontaneous rupture of the distal esophagus (Boerhaave's syndrome), as well as ischemia leading to necrosis and resultant loss of bowel wall integrity