A 66-year-old gentleman presented to the emergency department with an apparent exacerbation of his previously diagnosed chronic obstructive pulmonary disease (COPD). In addition to his shortness of breath, the patient complained of severe abdominal distention. The chest x-ray revealed apparent pneumoperitoneum, a surgical emergency. The liver was visualized in the left side of the abdomen, and the lung fields appeared to be hyperinflated (Figure 1). This was later determined to likely represent the air-filled hepatic flexure of the large intestine. Distention of the colon displaced the liver downward and to the left, leaving the impression of partial situs inversus. The subsequent computed tomography scan in both coronal and axial planes revealed distention of the hepatic flexure of the colon, and the liver was displaced leftward, inferior and anterior from anatomic position. The air-filled large intestine mimicked pneumoperitoneum on chest x-ray; both the coronal and axial slices revealed what was potentially free air. The lung fields revealed destruction of the alveoli with hyperinflation of the lungs, consistent with the history of COPD (Figure 2).
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