Puzzling peritonitis in an adolescent

A previously well 15-year-old boy presented with sudden onset, central abdominal pain, generalised tenderness and absent bowel sounds. Despite supportive management, he became shocked and pyrexial. Appendicitis was excluded by clinical examination; however, given the abdominal signs, further imaging was sought after a joint paediatric and surgical review. Abdominal ultrasound scan identified free intra-abdominal air, following which a CT scan was arranged. …