This action might not be possible to undo. Are you sure you want to continue?
The term pneumoperitoneum refers to the presence of air within the peritoneal cavity. The most common cause is a perforation of the abdominal viscus—most commonly, a perforated ulcer, although a pneumoperitoneum may occur as a result of perforation of any part of the bowel; other causes include a benign ulcer, a tumor, or trauma. The exception is a perforated appendix, which seldom causes a pneumoperitoneum. The presence of a pneumoperitoneum does not, however, always imply a perforation, because a number of other (mostly nonsurgical) conditions are associated with pneumoperitoneum. Likewise, not every bowel perforation results in a pneumoperitoneum; some perforations seal over, allowing little gas to escape. A pneumoperitoneum is common after abdominal surgery; it usually resolves 3-6 days after surgery, although it may persist for as long as 24 days after surgery. The peritoneum is a thin, serous membrane that lines the abdominal cavity. It has parietal and visceral layers, the latter being reflected over the abdominal viscera. A thin layer of serous fluid, which acts as a lubricant, separates the 2 layers. Several intra-abdominal organs are invaginated by visceral peritoneum to such an extent that they are almost completely covered by peritoneum; they have double layers of peritoneum within them as mesenteries and ligaments (see the images below).
Diagram of transverse section of the abdomen shows peritoneal reflection.
Diagram of a sagittal section of the female abdomen and pelvis shows peritoneal reflection.
Diagrams of the right upper quadrant show the location of the oblong collection of air in the right subhepatic space seen on a plain supine abdominal radiograph
Diagram of the right upper quadrant shows a triangle-shaped collection of air in the Morison pouch, as seen on a plain supine abdominal radiograph. This collection is usually bound by the 11th rib, and it may be triangular (doge's cap), crescent shaped, or semicircular
Diagram of the right upper quadrant shows the location of a circular collection of air projected over the liver interposed between the anterior liver surface and the anterior thoracic and abdominal wall seen on a plain supine abdominal radiograph. The most common cause of a spontaneous pneumoperitoneum is the introduction of air through the female genital tract (see the images below).
Pneumoperitoneum . Upright chest radiograph shows a large pneumoperitoneum outlining the spleen and the superior surface of the liver.
Pneumoperitoneum . (Left) Sagittal sonogram through the liver shows a comet-shaped artifact due to free air in the anterior subphrenic space, which causes shadowing. Also note the free peritoneal fluid. (Right) A transverse oblique sonogram through the midabdomen shows dilated loops of small bowel with a streak of free fluid between the bowel loops.
[3. 5] Limitations of techniques Free intraperitoneal air is often missed with plain radiology. and it is theoretically more sensitive than plain abdominal radiography. Also note the air surrounding the gallbladder and the leakage of water-soluble contrast material from a perforated duodenal ulcer. bladder (KUB) image is used instead of other images in cases of suspected pneumoperitoneum. The failure to detect free air is more a function of lacking standardization and of inadequate technique.[1. US examination also has the advantage of depicting other changes. pregnant women. US is usually the first investigation performed in emergent patients. 4. In most institutions. Despite the contrary consensus. ureter. These 4 . it provides exquisite scans. However. such as free abdominal fluid and inflammatory masses. 2] Compared with plain radiography.Pneumoperitoneum. and individuals of reproductive age. CT is not always required when a pneumoperitoneum is suspected. Preferred examination CT is regarded as the criterion standard for the detection of a pneumoperitoneum. US is a noninvasive test that is widely available and is particularly valuable in children. Contrast-enhanced axial CT scan through the liver shows a collection of air anterior to the liver. a kidney. the accuracy of supine abdominal radiography closely approximates CT when the entire abdomen is imaged. Some studies have reported sensitivities greater than that of plain abdominal radiography in the diagnosis of a pneumoperitoneum.
it is expensive in terms of both radiation burden and cost. Extraluminal gas Extraluminal gas may be involved in pneumoperitoneum or gas within an abscess or fistulous tract. and it has limitations in patients who are obese and in those with a large amount of intra-abdominal gas. or it may have sealed. which is often the key to the differential diagnosis. In addition. With both conventional radiology and CT.radiographs are insufficient for the diagnosis of a pneumoperitoneum because the uppermost portion of the peritoneal cavity. it remains operator dependent. The leak may be too small. Although US is a noninvasive and relatively inexpensive test. oral contrast material is used to opacify the lumen of the GI tract and to demonstrate a bowel leak. When a distal small or large bowel perforation is suspected. may be excluded from the examination. If proper technique is applied. and extravasation of the contrast material may not occur. one major limitation of the use of oral contrast material is that several hours may be required to opacify the bowel. although these may not be relevant in terms of bowel perforation. contrast-enhanced studies and CT scanning can be avoided. which reveals important signs. such as the presence of an appendicolith and bowel hemorrhage. Although a CT scan is considered a criterion standard in the diagnosis of a pneumoperitoneum. 7] Abnormal abdominal gas collections are classified according to the anatomic location. oral contrast material may obscure relevant clinical information. Gas within an abscess 5 . the randomness of bowel opacification. the difficulty encountered in securing the cooperation of a sick patient. Gas within a pelvic abscess usually indicates that the abscess is of GI origin.[6. and the relative clinical urgency for diagnosis limit the value of oral contrast enhancement. Thus.
The differential diagnosis between liver microabscesses and microcalcification may be difficult to make with US. or within the biliary tree. Intratumoral gas may also be seen in hepatic tumors after chemoembolization. Adjacent bowel 6 . Intraparenchymal gas Within the portal vein. within an obstructed Meckel diverticulum (secondary infection). intraparenchymal gas may sometimes be seen on real-time US as gas microbubbles moving through the liver or as linear collections of hyperlucent branching gas at the periphery of the liver. in such cases. Normal intraluminal gas can be differentiated by the presence of gas within the bowel lumen in association with peristalsis that is visible on fluoroscopy or ultrasonography (US).of pelvic inflammatory disease (PID) is unusual. intraparenchymal gas usually indicates an abscess. Intratumoral gas Intratumoral gas typically occurs in a gastric leiomyoma or leiomyosarcoma. Gas may be seen in a liver abscess. intramural. Gas within the paracolic gutter is usually associated with GI perforation. Intraluminal gas Intraluminal gas may be normal or abnormal. The gas may be intratumoral (within a neoplasm in association with infection or bowel communication). differentiation of the gas from an abscess may be difficult with the use of images alone. within a paralyzed loop of bowel. In most other organs. US features that are distinctive of infection include high-amplitude echoes that do not change with the patient's position or with peristalsis. Diverticulitis may produce extraluminal gas trapped within the adjacent mesentery. Intramural gas Intramural gas may be related to ischemia. the gas may be seen extending from the lumen of the stomach into the tumor. in such cases.
Confusion may occur with mural calcification. The most common cause is perforation of a peptic ulcer. At the level of the umbilicus. Crohn disease and cytomegalovirus (CMV) infection are less common causes of intramural bowel gas. Pneumatosis coli is often better shown with CT than with US. The median umbilical 7 . the peritoneal cavity is completely closed. Male versus female anatomy In males.wall thickening is often present. Acute emphysematous cholecystitis. but there is little clinical evidence of peritonism. Occasionally. which provide a potential pathway for suction of air into the peritoneal cavity. They are treated expectantly and do not require surgery. which is often curvilinear but which does not have the characteristic ring-down artifact associated with air bubbles. Patients with such conditions need urgent surgery. but in females. Peritoneal reflections and ligaments Various peritoneal reflections and ligaments interrupt the peritoneal cavity. The fallopian tubes also constitute a possible pathway of infection from the genital tract. These patients have a pneumoperitoneum without peritonitis. the obliterated fetal urachus (median umbilical cord) forms a shallow ridge that extends cephalad from the dome of the urinary bladder to the umbilicus. patients with vague abdominal symptoms have unequivocal features of a pneumoperitoneum. which often occurs in diabetic patients and the elderly. the peritoneal cavity communicates with the genital tract via the fallopian tubes. shows evidence of intramural gas on US. The presence of free intra-abdominal gas usually indicates a perforated abdominal viscus. Adenomyosis of the gallbladder may cause a comet-tail artifact.
forms the left wall of the lesser sac. the stomach. which represent the obliterated umbilical arteries. The free edge of the lesser omentum between the porta hepatis and duodenum contains the portal vein. which enclose the bare area of the liver. The spleen. The lesser sac lies behind the lesser omentum and the stomach. The right of the sac communicates with the main peritoneal cavity via the foramen of Winslow. which is attached by the gastrosplenic and lienorenal ligaments. In the free edge of the falciform ligament lies the ligamentum teres (the obliterated fetal left umbilical vein). respectively. Superiorly.cords. the hepatic artery and common bile duct lie anteromedially and anterolaterally. which passes from the liver to the esophagus. peritoneal layers form the triangular and coronary ligaments. The layers of peritoneum investing the liver unite on its visceral surface to form the lesser omentum. It passes backward and splits to enclose the liver. The falciform ligament is a double layer of peritoneum that forms anteriorly near the midline between the umbilicus and the esophagus. 8 . which passes into the groove between the quadrate lobe and the left lobe of the liver. which is attached posteriorly to the anterior aspect of the pancreas. The transverse colon is enclosed by the transverse mesocolon. These reflections and peritoneal spaces are important radiologically because it is here that air accumulates in a pneumoperitoneum. and the first part of the duodenum. extend from the internal iliac arteries to the umbilicus in the shape of an inverted V. The layers of the lesser omentum split to enclose the stomach and then reunite to form the greater omentum and gastrosplenic and lienorenal ligaments.
US is readily available in most centers and can be used in the pregnant patient. bowel dilation. use of standard upright posteroanterior (PA) radiographs resulted in a confirmation in only 80% of patients. the decision to use further imaging such as CT or to perform surgical exploration must be made on an individual basis. in such instances.Special concerns Most pregnant women (90%) experience significant improvement or complete resolution of peptic ulcer disease. For cases in which there is strong clinical suspicion but the radiographic findings are negative. the fetus is excluded from the direct beam. Woodring and Heiser found that use of upright lateral chest radiographs led to a confirmation of pneumoperitoneum in 98% of patients . bowel thickening. With lateral chest radiography. Negative findings support conservative management. Pneumoperitoneum has a variety of causes. Complications of peptic ulcer disease such as hemorrhage and perforation are rare in pregnancy. but the use of conventional radiography involves irradiation of the fetus. The study also revealed that CT features of mesenteric stranding. suggesting that upright lateral views are more sensitive than standard upright PA chest radiographs. Pneumatosis intestinalis may be associated with benign causes or may occur in patients with intra-abdominal cancer. the benefit outweighs the disadvantage of the small radiation dose to the fetus. In a series of 100 patients. portomesenteric 9 . Radiology has a role in the evaluation of suspected perforation. by contrast. the physician should not hesitate to perform a full abdominal series when the index of clinical suspicion is high. including pneumatosis intestinalis. Lee and associates retrospectively and blindly reviewed 84 patients with pneumatosis intestinalis to determine the overall proportion of clinically worrisome and benign pneumatosis intestinalis occurring in patients with cancer and to evaluate associated risk factors on CT. Although a negative lateral chest radiograph excludes a pneumoperitoneum in most cases. The study revealed that benign pneumatosis intestinalis was more prevalent than clinically worrisome pneumatosis intestinalis.
10 . cystic. A lateral chest x-ray has been found to be even more sensitive for the diagnosis of pneumoperitoneum than an erect chest x-ray. Radiography Optimal radiographic technique is important with a suspected abdominal perforation. or both. including a supine abdominal radiograph and either an erect chest image or a left lateral decubitus image. The location and pattern. The images below depict radiographic technique. were also important. Pneumoperitoneum .venous gas and ascites.Plain radiograph of the right upper quadrant shows a tiny streak of air under the diaphragm due to a pneumoperitoneum. At least 2 radiographs should be obtained. and localization confined to the small bowel were worrisome signs. Pneumoperitoneum . such as linear.Upright chest radiograph shows a large collection of air under both hemidiaphragms due to perforated duodenal ulcer. The patient should remain in position for 5-10 minutes before a horizontal-beam radiograph is acquired.
11 . Note also the air-fluid levels within the bowel due to associated ileus. a perforated terminal ileum secondary to Crohn disease was diagnosed.Upright chest radiograph shows a large pneumoperitoneum outlining the spleen and the superior surface of the liver. (Left) Supine radiograph of the right upper quadrant shows a vague lucency overlying the liver.Pneumoperitoneum . Pneumoperitoneum .Images in a 24-year-old man known to have Crohn disease who presented with acute abdominal pain. At surgery. (Right) Lateral decubitus radiograph shows an obvious pneumoperitoneum.
which is a sign of a large pneumoperitoneum on a plain abdominal radiograph. Her main complaint was hip pain.This elderly patient was knocked down by a car in a motor vehicle accident.Pneumoperitoneum . but also note a bowel relief sign (arrow).Coned view of the lower abdomen shows the lateral umbilicus sign (arrow). At surgery. Pneumoperitoneum . a perforation of the small bowel secondary to blunt abdominal trauma was confirmed. 12 . Note also the bowel relief sign. Plain abdominal radiograph of the pelvis confirms the presence of a fracture of the neck of the left femur.
Pneumoperitoneum . which is another sign of a large pneumoperitoneum on a plain abdominal radiograph. Supine abdominal radiograph shows an elliptical collection of air within the subhepatic space. Coned view of the lower abdomen shows the urachus sign (arrows). 13 .Pneumoperitoneum . Note also the bowel relief sign. Diagrams of the right upper quadrant show the location of the oblong collection of air in the right subhepatic space seen on a plain supine abdominal radiograph.
Plain abdominal radiograph of a patient with a pneumoperitoneum shows a triangular collection of air in the Morison pouch (solid arrows). as seen on a plain supine abdominal radiograph. Pneumoperitoneum . This collection is usually bound by the 11th rib. or semicircular.Diagram of the right upper quadrant shows a triangle-shaped collection of air in the Morison pouch. and it may be triangular (doge's cap). crescent shaped. Also note the bowel relief sign (open arrows). (Left) Supine chest radiograph shows a tiny collection of air under the diaphragm (arrow) in a patient with pneumoperitoneum. (Right) Supine abdominal radiograph shows a triangular collection of air in the Morison pouch (arrow). 14 .
he had a sudden onset of acute abdominal pain. but note the pearshaped lucency projected over the liver indicative of a pneumoperitoneum. but note the triangular collection of air within the Morison pouch. While he was in the ward. an upper GI series performed with water-soluble contrast material was requested. 15 . Findings on this supine radiograph were interpreted as being normal. A 49-year-old man was admitted to the hospital with acute abdominal pain. (Left) Radiograph obtained early in the study shows no leakage. Findings from the initial plain abdominal radiographs were interpreted as being normal. A 66-year-old man was admitted to the hospital with urinary retention and was being examined for prostatic pathology. (Right) When this earlier plain radiograph was interpreted. this had escaped detection earlier (arrow). Because the cause of his abdominal pain was not clear.Diagram of the right upper quadrant shows the location of a circular collection of air projected over the liver interposed between the anterior liver surface and the anterior thoracic and abdominal wall seen on a plain supine abdominal radiograph. the collection of air within the Morison pouch was seen.
Radiograph shows barium within the stomach. a perforated duodenal ulcer was confirmed. 16 . Note the duodenal ulcer crater and air within the ligamentum teres (arrow). but note air within the lesser sac and in the Morison pouch. Supine abdominal radiograph shows a falciform ligament (arrow).Supine abdominal radiograph in a 26-year-old man with known Crohn disease who presented with acute abdominal pain. (Left) Upper GI barium series in a patient who presented with acute abdominal pain. (Right) Follow-up barium study shows that the barium leak and air within the ligamentum teres (arrow) persists. At surgery. Pneumoperitoneum. Findings on the initial plain radiographs were interpreted as normal.
Plain abdominal radiograph in a 24-year-old man who presented with acute abdominal pain 24 hours after undergoing an upper GI series with barium. The bowel relief sign is obvious. although she had no abdominal signs. she was observed. At surgery. Radiography was performed to evaluate peptic ulcer disease. Note also the delineation of the falciform ligament of the escaped barium. 17 . a repeat anteroposterior (AP) chest radiograph was obtained because the patient felt vaguely unwell. Note the air-fluid level to the left of the upper lumbar spine and left basal pleural effusion. (Right) Two weeks later. a retroperitoneal abscess secondary to a colonic perforation was diagnosed. Also seen is barium within the grooves of mesenteric vessels (arrows). Posteroanterior (PA) chest radiograph in a patient receiving long-term steroid therapy who presented with breathlessness but no abdominal symptoms.Pneumoperitoneum . Note that barium has been released into the anterior subphrenic space (arrows). A large pneumoperitoneum is present. Pneumoperitoneum . Patients who are diabetic or those taking steroids are prone to silent perforations.Left. and because of the lack of abdominal signs.
The patient was treated conservatively because of a lack of abdominal signs. Chest radiograph (left) and plain radiograph (right) show surgical emphysema and retroperitoneal air secondary to a retroperitoneal bowel perforation.This patient was unwell after endoscopic retrograde cholangiopancreatography (ERCP). Pneumoperitoneum . Pneumoretroperitoneum. He recovered fully. 18 .Pneumoperitoneum . Plain abdominal radiograph shows a falciform ligament (arrow) and the bowel relief sign.Plain abdominal radiograph in a patient in whom a retropneumoperitoneum developed after endoscopic retrograde cholangiopancreatography (ERCP).
Pneumatosis coli secondary to necrotizing enterocolitis. 19 . Note the large pneumoperitoneum and air within the portal venous radicals. Pneumoperitoneum mimics . Pneumoperitoneum mimics.Image shows bowel perforation after bowel infarction. Large bulla at the base of the right lung mimics a large pneumoperitoneum. Pneumoperitoneum mimics. Plate atelectasis at the right lung base mimics a small pneumoperitoneum.Pneumoperitoneum .
Air within the portal venous radicals secondary to bowel infarction is an ominous sign in adult patients. Image shows air within the biliary tree after papillotomy. which becomes cumbersome for patients who are ill and in pain. Image colonic interposition. mimics. shows Pneumoperitoneum mimics . Air-containing bowel loops within a Morgagni hernia. Pneumoperitoneum mimics . Pneumoperitoneum mimics .Pneumoperitoneum. which includes the acquisition of a left lateral decubitus image after the patient is in the proper position for 20 minutes and the acquisition of an upright radiograph after 5 minutes and a supine radiograph after 1 minute. Some authors suggest a complete free-air series. 20 . Note the haustra. The total examination time is therefore 26 minutes.
A telltale triangle sign represents a triangular pocket of air between 2 loops of bowel and the abdominal wall. Some authorities apply the term football sign to the air surrounding the falciform ligament.[10. The base of the urachus may be slightly thicker than the apex. Free intraperitoneal gas and intraperitoneal fluid in excess of 1000 mL are usually required to elicit this sign. 11. 21 . The gas-relief sign. It has the same opacity as other soft tissue intra-abdominal structures. The air seems to outline the entire abdominal cavity. The urachus is a vestigial peritoneal reflection not normally seen on a plain abdominal radiograph. 12. The urachus is then seen as a thin midline linear structure in the lower abdomen proceeding cephalad from the dome of the urinary bladder. which contain the inferior epigastric vessels. but when a pneumoperitoneum occurs. the Rigler sign. Scrotal air may be seen in children as a result of peritoneal intrascrotal extension (through patent process vaginalis). may become visible as an inverted V sign in the pelvis as a result of a large pneumoperitoneum. The lateral umbilical ligaments. which looks like the laces of a football. 13] Signs of a large pneumoperitoneum Signs of a large pneumoperitoneum include the following: The football sign. which usually represents a large collection of air within the greater sac. air outlines the urachus. and the double-wall sign are all terms applied to the visualization of the outer wall of bowel loops caused by gas outside the bowel loop and normal intraluminal gas.The plain radiographic signs of a pneumoperitoneum have been classified into those of a small pneumoperitoneum and those of a large pneumoperitoneum associated with more than 1000 mL of free air.
 An oblong saucer-shaped or cigar-shaped collection of air may be present in the subhepatic space inferior to the lower edge of the liver. which forms the least dependent part of the abdomen in that position. or pear-shaped collection of air may be projected over the liver shadow between the ventral liver surface and the anterior thoracic or abdominal wall. Gas within the lesser sac may be present. though such gas does occur in association with the following conditions: colonic interposition. Right upper quadrant gas Menuck et al published an important report in 1976 describing the importance of right upper quadrant gas. On a left lateral decubitus radiograph. free air is apparent around the inferior edge of the liver. or triangular. a point at which free air may be present. This has been likened to a doge's cap. The configuration of this air collection varies and may be semicircular. crescent shaped. which is best seen in a small pneumoperitoneum on supine radiographs. particularly women. The liver shadow normally has no gas overlying it. Signs of partial large bowel obstruction with a sigmoid diverticulum perforation may occur in association with signs of a pneumoperitoneum. This collection may be solitary or present in several smaller locules. liver 22 . In obese patients. the least dependent part may be overlying the hips. Free air under the diaphragm may depict the diaphragmatic muscle slips as arcuate soft tissue bands. oval. subphrenic abscess. particularly with a perforation of the posterior wall of the stomach. which is bound by the left 11th rib. A round. arching parallel to the diaphragmatic dome. Air may be present around the spleen. A triangular collection of air may be seen in the Morrison pouch.
and as an effect of chemoembolization. as assessed on plain radiographs. The gas collection may be 2-7 mm wide and 6-20 mm long. Air in the gallbladder fossa is a recently described sign that is better demonstrated with CT than with radiography. Parahepatic gas bubbles may be seen lateral to the right edge of the liver. the presence of biliary gas. patients with an acute abdomen and suspected perforation have no free gas. The cupola sign (saddlebag or moustache sign) represents gas trapped under the central tendon of the diaphragm.abscess with gas-forming organisms. but it has also been described with a pneumoperitoneum. The differential diagnosis usually includes acute cholecystitis. Gas within the ligamentum teres is seen as a vertical slitlike or oval lucency lying between the 11th and 12th right ribs and 2. The falciform ligament is a linear soft tissue opacity coursing vertically between the umbilicus and the ligamentum teres notch in the inferior surface of the liver. the presence of portal venous gas. Gas within the ligamentum teres notch may be seen as an inverted V–shaped collection on the undersurface of the liver at the junction of the right and left lobes. pancreatitis. The falciform ligament may be thin and of uniform diameter. 23 . Use of contrast medium in the evaluation of suspected perforation Not infrequently.5-4 cm lateral to the spinal edge. and a perforated ulcer. Small collections of air around the periduodenal area normally occur with a retroperitoneal perforation in the second part of the duodenum. but it is occasionally a linear lobulated structure that may be several millimeters thick.
contrast material may leak into the peritoneum. The use of ionic water-soluble contrast medium should be avoided because patients may inadvertently inhale it. gas overlies the right upper quadrant. In approximately one half of patients with a pneumoperitoneum. about 50 mL of water-soluble contrast agent is given orally or via a nasogastric tube with the patient lying right-side down. spot images are obtained after the patient stays in the right lateral decubitus position. In patients with a perforated ulcer. and plain abdominal radiography may be performed. Fluoroscopy is not always essential.To aid in the examination. stretched duodenal loop may be visualized. in these patients. Chilaiditi syndrome) (see the following image) 24 . Degree of confidence Plain radiography remains the mainstay in imaging an acute abdomen. False positives/negatives Mimics of a pneumoperitoneum include the following: Colonic interposition between the superior surface of the liver and the diaphragm. including a perforated abdominal viscus. Patients with pancreatitis may also be examined with this technique. an edematous. As little as 1 mL of free gas can be detected on a plain radiograph—either an erect chest image or a left lateral decubitus abdominal image. Fluoroscopy may be used to examine the patient. Pneumoperitoneum is detectable in 56% of patients by using a supine abdominal image.
Plate atelectasis at the right lung base mimics a small pneumoperitoneum. Undulating diaphragm Basal atelectasis situated above and parallel to the diaphragm.Pneumoperitoneum mimics .Image shows colonic interposition. which is bandlike and has a normally aerated lung above and below (see the following image) Pneumoperitoneum mimics . Basal lung bulla (see the image below) 25 . Note the haustra.
Subphrenic fat has a curvilinear lucency. which is usually in a more lateral position 26 . Pneumatosis coli secondary to necrotizing enterocolitis. Subphrenic abscess caused by gas-forming organisms Pyonephrosis caused by gas-forming organisms Supradiaphragmatic curvilinear pulmonary collapse Cysts of pneumatosis coli (see the following image) Pneumoperitoneum mimics .Pneumoperitoneum mimics . Large bulla at the base of the right lung mimics a large pneumoperitoneum.
Fat in the fissure of ligamentum teres 27 . Air in the portal venous system Pneumoperitoneum mimics . Pneumoretroperitoneum Mimics of ligamentum teres fissure gas include the following : Air in the biliary tree Pneumoperitoneum mimics . Air within the portal venous radicals secondary to bowel infarction is an ominous sign in adult patients. Image shows air within the biliary tree after papillotomy.
[17. as in the images below. 19. 28 . anteriorly placed gas can generally be differentiated from gas within the bowel. 22. Animal experiments have revealed that CT can depict as little as 5 cm of cubic free air in the peritoneum. With any perforation. Also note the air surrounding the gallbladder and the leakage of water-soluble contrast material from a perforated duodenal ulcer. The cause of the perforation can sometimes be diagnosed. or appendicitis. In a supine position. the amount depends on the site of perforation. 21. an outpouring of inflammatory fluid of varying quantities can be observed within the peritoneum. Nonenhanced axial CT through the tip of the liver shows leakage of oral contrast material (arrows) from a perforated gastric ulcer. Such perforations may be associated with a carcinoma. This fluid is again readily detected with CT. diverticulitis. 23] Contrast-enhanced axial CT scan through the liver shows a collection of air anterior to the liver. 18. 20.Computed Tomography CT can readily depict a pneumoperitoneum.
CT is useful in identifying even a small amount of extraluminal gas. or peritoneal dialysis. The presence of free gas in the peritoneum is nonspecific. particularly when plain radiographic findings are nonspecific. recent surgery. In addition. False positives/negatives CT does not always help in differentiating between pneumoperitoneum of benign cause and pneumoperitoneum caused by a condition that requires urgent surgery. it is difficult to localize the site of the perforation. CT is less dependent on the patient's position and the technique used. 29 . Degree of confidence CT is regarded as a criterion standard in the assessment of a pneumoperitoneum. It may be the result of bowel perforation. The anteriorly located gas from a pneumoperitoneum is sometimes difficult to differentiate from gas in a distended bowel.Posterior perforation of a duodenal ulcer showing inflammatory fluid around the gallbladder mimicking acute cholecystitis. with CT.
A localized gas collection related to bowel perforation may be detected. The presence of bowel peristalsis can blur the bowel wall. (Right) A transverse oblique sonogram through the midabdomen shows dilated loops of small bowel with a streak of free fluid between the bowel loops.Magnetic Resonance Imaging Pneumoperitoneum can be seen as an area of low signal intensity on images obtained with all sequences. such as bowel wall thickening. particularly if it is adjacent to other abnormalities seen on US. Pneumoperitoneum. pneumoperitoneum appears as a linear area of increased echogenicity with distal ring-down or reverberation artifact. Ultrasonography On sonograms. (Left) Sagittal sonogram through the liver shows a comet-shaped artifact due to free air in the anterior subphrenic space. as depicted in the images below. Pneumoperitoneum can be an incidental finding on MRI because MRI is not the primary imaging modality. which causes shadowing. 30 . Also note the free peritoneal fluid.
may be observed. At times. Scanogram obtained prior to CT shows the falciform ligament (arrow) and leakage of oral contrast medium (L) secondary to a pneumoperitoneum. Pneumoperitoneum is best seen around the perihepatic space in the supine or lateral decubitus position. Reverberation of the sound beam may occur between gas and the transducer.5-5. The reverberation echoes are "dirty" in comparison with clear shadowing from calculi. The following US findings have been described: Total sound reflection may occur at the interface of soft tissue and/or air. High-amplitude linear echoes with distal artifactual reverberation echoes.Pneumoperitoneum. the small gas bubbles are difficult to differentiate from microabscesses or microcalcification. Gas in a fistulous tract is usually associated with Crohn disease. which may be periodic. Small reverberation artifacts have a characteristic comet-tail appearance. The location of the gas collection is often the key to the differential diagnosis. 31 . Small gas collections may show little or no distal reverberation artifacts with standard abdominal transducers (3.0 MHz). Gas collection in the paracolic gutter is usually caused by GI perforation.
and colonic gas anterior to the liver-colonic interposition. and it is of limited use in obese patients and in those with a large amount of intra-abdominal gas. gas is unusual in PID. porcelain gallbladder. pregnant women. It is less expensive than CT. Portal venous gas may be seen as discrete gas bubbles moving toward the periphery of the liver with the bloodstream. or air within the portal vein. and individuals of reproductive age. 32 . Degree of confidence US is readily available in most centers. In the appropriate clinical setting. Normal intra-abdominal gas is intraluminal. However. False positives/negatives Mimics of a pneumoperitoneum include shadowing from a rib. the presence of gas bubbles within a complex fluid collection suggests an abscess. gallbladder calcification. adenomyosis. extraluminal gas may be trapped within the adjacent mesentery. US remains operator dependent. ring-down artifacts from adjacent air-filled lung. In cases of diverticulitis. and it is particularly valuable in patients for whom a radiation burden is a major concern. Apart from gas in the liver. mural calcification. Gas within a pelvic abscess is usually of GI origin. with the surrounding bowel usually seen and associated with bowel peristaltic movements. US should not be considered definitive in excluding a pneumoperitoneum. Gas in the right upper quadrant may be confused with emphysematous cholecystitis. Knowledge of the abdominal anatomy. is critical for an accurate interpretation of gas in an abnormal location. particularly peritoneal reflection. air within an abscess. tumor. These patients include children. biliary gas. gas within other organs is usually secondary to an abscess.
Lamacchia M.8(3):267-79. Braccini G. Markogiannakis H. Lee KS. 17. 14. Jul 1995. Boraschi P. Jan 1998. [Medline]. Van Allan RJ. Am J Surg. Oct 1997. [Medline]. 16. discussion 6267.89(3):351-4.127(5):753-6. Woodring JH. Ottinger D. Plain films and cross-sectional imaging for acute abdominal pain: unresolved issues. Abdom Imaging. 11. Weigelt JA. Depiction of diaphragmatic muscle slips on supine plain radiographs: a sign of pneumoperitoneum. Cho KC. 2. [Medline].[Medline]. Rúa SM. [Medline]. [Medline]. Weigelt JA. Pneumoperitoneum: importance of right upper quadrant features. The visible gallbladder: a plain film sign of pneumoperitoneum. Rigler sign: an underappreciated alert for pneumoperitoneum. Williams N. [Medline].21(5):404-12. Wang HP. Baker SR. [Medline]. Swanson JR. Radiology. Jun 1999. Mar 2002. where intestinal loops are not usually found. Heiser MJ. [Medline]. Jul 1996. Arch Surg. Ultrasonography is superior to plain radiography in the diagnosis of pneumoperitoneum. 12. Rossi G. The technical approach to the acute abdomen. 3. AJR Am J Roentgenol. Spaniolas K. Siemers PT. Miller RE. Nov 1976. Rosen RS. 4. Am J Roentgenol. Distinguishing benign and life-threatening pneumatosis intestinalis in patients with cancer by CT imaging features. May 2013. However. 10.20(2):142-7. even a small amount of free air can be detected anteriorly or anterolaterally between the abdominal wall and adjacent liver. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. McGonigal MD. Acta Radiol. discussion 6267.205(1):45-7. 13.202(3):651-4. May 1997. Jul 1973. Jan 1997. May 2008. Ultrasound versus plain film in the detection of pneumoperitoneum. Fili K. ultrasonography and CT in jejunoileal perforation. Hwang S. [Medline].134(6):622-6. 15. Differentiating extraluminal gas from intramural or intraluminal gas is difficult. Bizimi V. Br J Surg.Intraperitoneal gas is frequently more difficult to detect than gas in abnormal locations because of adjacent intraluminal gas. 6. Menuck L. Semin Ultrasound CT MR. Unenhanced helical CT versus plain abdominal radiography: a dissenting opinion. Stafford RE. Baker SR. Baker SR. Cho KC. Arch Surg. 9. Radiology.200(5):1042-7. Am J Perinatol.25(5):291-3. Mar 1997. Semin Roentgenol. 8. Stafford RE. Radiological confirmation of intraperitoneal free gas. 5. 33 . Visualization of the extrahepatic segment of the ligamentum teres: a sign of free air on plain radiographs. Baker SR. AJR Am J Roentgenol. [Medline]. References 1. AJR Am J Roentgenol. Oral contrast solution and computed tomography for blunt abdominal trauma: a randomized study. [Medline]. [Medline]. McGonigal MD.134(6):622-6.165(1):45-7. Katsiva V. Conventional plain-film radiology. Ann R Coll Surg Engl. Theodorou D. [Medline]. Chen SC. Pinto A.79(1):8-12. 7. Oral contrast solution and computed tomography for blunt abdominal trauma: a randomized study. Yen ZS. Jun 1999. Diagnosing intestinal perforation: a new approach. Everson NW.39(1):52-6. [Medline].167(1):69-70. Gollub MJ. Janjigian YY. Apr 1999. [Medline]. Radin R. Grassi R. [Medline].203(2):431-3. Radiology. Sep-Oct 1996. Apr 22 2008.
duration. Colon E.48(41):1393-6. Chen CH.161(4):781-5. Yang CC. 34 . Sep 1996. Moore SL. O'Donohue B. 24. AJR Am J Roentgenol. 22. [Medline]. Sajith A.18. Wang HP. [Medline]. Huang HS.25(2):115-6.25(3):301-5. [Medline]. Balthazar EJ. Chen CH. Sep-Oct 2001. Mar 2008. Apter S.9(6):643-5. Jonas T. Earls JP. Sep-Oct 2001. [Medline]. Hepatogastroenterology. Jun 2002. Emerg Med J. Gayer G. [Medline]. CT evaluation of infradiaphragmatic air in patients treated with mechanically assisted ventilation: a potential source of error. and relevant factors affecting its possible significance. Khan RA. Acad Emerg Med. May-Jun 2000. Yang CC. Chen SC. 21. [Medline]. 20. The features of perforated peptic ulcers in conventional computed tomography. 23.167(3):731-4. Dachman AH. The features of perforated peptic ulcers in conventional computed tomography. CT scan findings in oesophagogastric perforation after out of hospital cardiopulmonary resuscitation. Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography. Postoperative pneumoperitoneum as detected by CT: prevalence. Huang HS. Selective use of ultrasonography for the detection of pneumoperitoneum. 19. Oct 1993. Hepatogastroenterology. [Medline].48(41):1393-6. Abdom Imaging. AJR Am J Roentgenol. Chen WJ. Roth RM.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.