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SUMMARYA case is reported of a pneumopericardium in a 69-yearold woman caused by the rupture into the pericardium of a gastric ulcer situated in a hiatus hernia. Gastrografin studies were used to confirm the diagnosis and her initial conservative management was successful. However, she died at the operation to close her fistula, probably largely as a result of multiple unsuspected pulmonary emboli compounding her acid pericarditis.

The high level of accuracy achieved by some ultrasonographers in the diagnosis of gall stones' 2 has resulted in a general acceptance of ultrasound as the primary investigation for gall stones.3 These excellent results, however, were obtained by strongly motivated and highly experienced ultrasonographers conducting clinical trials.4 The knowledge that the result of an ultrasound examination will be included in a prospective study may improve performance. We have sought to establish whether the same level of accuracy can be achieved when ultrasound is performed outside the confines of a prospective trial by ultrasonographers with varying degrees of experience.The purposes of this study were, firstly, to assess the performance of gall bladder ultrasound in a busy radiology department where gall bladder ultrasound is routinely performed by different radiologists and, secondly, to see whether there was "operator variability" between the ultrasonographers performing the scans. The results were examined retrospectively and represent a record of what occurred in our department without the possible bias which would be introduced by a prospective study. Methods and resultsWe analysed the results of 402 ultrasound examinations of the gall bladder performed on a Sonotron Diasonic DS1 real time scanner, using a 3-5 mHz probe, during a two year period up to June 1984. The scans were performed by four consultant radiologists (operators 1-4) and various registrars and

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