Clinical presentation

A middle-aged patient with cystic fibrosis presented to the clinic with progressively worsening constipation requiring over-the-counter laxative use. He was not in distress, and physical examination was notable for percussive tympany over the right upper quadrant with caudally displaced liver. Review of laboratory analysis was unremarkable, including normal cell count, electrolytes, hepatic function and negative coeliac panel. Assessment of previous CT imaging of the abdomen unexpectedly revealed air under the right diaphragm (figure 1 …