clinical presentation of gas under the diaphragm and acute abdomen can be due to rupture of viscus , perforated peptic ulcer disease and rarely spontaneous .
a 38 year old woman presented in accident and emergency ward with a history of acute abdominal pain .
she gave a history of dyspepsia , symptoms of gastritis in the past and was treated with omeperazole .
she was seen by surgeons who advised for an erect chest x - ray which showed gas under the diaphragm implying the diagnosis of perforated peptic ulcer disease .
erect chest x - ray highlighting the presence of subphrenic gas she was seen b they gynaecology team in view of history and acute abdomen .
a detailed history was elicited and patient reported having had sexual intercourse earlier on the same day and denied the pain following it .
her vital signs were stable and abdominal examination revealed diffuse vague tenderness , no sign of distension or guarding and vaginal examination was difficult and no abnormalities detected .
in view of the clinical symptoms and radiological findings patient was taken for emergency laparatomy .
there was no perforation of viscus but there was a defect noted in the vaginal vault .
gas under the diaphragm can be due to like perforation in stomach , duodenum due to peptic ulcer disease , in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum .
this can present as an acute symptom.(1 ) 10% of cases diagnosed on pneumoperitoneum are not due to perforation of an air containing viscus but due to sexual activity , peritonitis , gas forming bacteria and some rare causes like iucd .
first case of pneumoperitoneum due to post coital perforation after abdominal hysterectomy has been reported in 1980.acute abdomen may or may not be the symptom ( 2,3 ) .
vaginal evisceration may or may not be a presenting symptom.(3,4 ) in our patient the acute symptoms and x - ray findings lead for an early laparatomy
. this condition could have been managed conservatively if the pain has not been severe .
the vault repair can be corrected laparoscopic or vaginally and a major laparatomy could be avoided embarrassment and modesty often prevent patients form talking about sexual activity .
clinical examination during acute pain , particularly vaginal examination , is more painful for patients .
the condition is rare but gynaecologist and surgeons should be aware of the situation and appropriate team work is essential to deal with the rare situations .
 gas under the diaphragm can be due to like perforation in stomach , duodenum due to peptic ulcer disease , in jejunum or illeum by inflammatory bowel disease or cancer can lead to pneumoperitoneum . 
 we present a rare cause of pneumoperitoneum following abdominal hysterectomy . 
INTRODUCTION
CASE REPORT
DISCUSSION