We present the case of a 37-year-old male with history of amyotrophic lateral sclerosis (ALS) and recent percutaneous endoscopic gastrostomy (PEG) tube placement presented with abdominal pain, nausea, vomiting, abdominal distention, tenderness and guarding. Given the concern for peritonitis, upright/decubitus chest X-ray was obtained and showed bilateral free peritoneal air suggesting possible perforation or peristomal leakage after PEG tube placement. While PEG complication rates are relatively low, clinicians should consider them and remember that chest X-ray can be a very efficient and accurate method of evaluation for possible gastrointestinal perforation, especially in acute emergencies.TopicsAbdominal/gastrointestinal, peritonitis, perforation, surgical complication.