Which radiographic finding may indicate perforation in peptic ulcer disease?

• A. Gallstones on ultrasound
• B. Dilated bowel loops
• C. Elevated amylase
• D. Free air under the diaphragm on an upright chest X-ray

Answer: (D)

Air in the peritoneal cavity from a perforated ulcer rises with gravity and shows up beneath the diaphragms on an upright chest X-ray. This pneumoperitoneum is the classic radiographic clue that perforation has occurred in peptic ulcer disease, and it often prompts urgent surgical evaluation. The other findings listed don’t specifically indicate perforation: gallstones on ultrasound reflect cholelithiasis, dilated bowel loops suggest obstruction or ileus, and elevated amylase can occur in pancreatitis or other conditions. The presence of free air under the diaphragm is the key imaging sign of perforation.