Pneumoperitoneum

Introduction
Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity.
The plain films signs of pneumoperitoneum are both diverse and sometimes
difficult to identify. This page provides an overview of the plain film diagnosis of
pneumoperitoneum.

Why is Pneumoperitoneum Important?

Pneumoperitoneum is most often caused by perforated abdominal viscus and can
present an acute medical emergency.

“The Radiological signs of pneumoperitoneum are among the most important signs in radiology,
indeed in Medicine. Sometimes the amount of free gas is small and you may have to work to
demonstrate it (i.e. modify the film technique). Miss it and the patient may die”
Abdominal X-rays made easy. 2nd edition, James D. Begg
Churchill Livingstone, Elsevier, 2006
p94

Plain Film Signs of Pneumoperitoneum

Radiographers are more likely to demonstrate pathologies that they are familiar
with. As James Begg stated, sometimes you have to 'work to demonstrate
pneumoperitoneum'. What he meant by this is that the supine signs of
pneumoperitoneum may be subtle- the radiographer must be able to identify the
signs on the supine image and know what supplementary views will prove the
existence of free intraperitoneal gas.

“We diagnose what we look for

and look for what we know”
The plain film signs of pneumoperitoneum are well established in the literature as
follows
1 Anterior Subhepatic Space Air
2 Doges Cap Sign (free Air in Morrison's Pouch)
3 Air Anterior to Ventral Surface of Liver
4 Rigler’s sign on supine AXR (also known as double-wall or bas-relief sign)
5 Falciform Ligament Sign
6 The ‘football’ sign
The cupola. Air accumulation beneath the central tendon of the
7
diaphragm
8 Continuous diaphragm sign
9 The triangle- air trapped between three loops of bowel
10 Air under diaphragm on erect cxr
11 Air outlined against liver/flank on decub AXR
Other-
12 diaphragmatic muscle slips, ligamentum teres air, Double Gastric Fundus
sign, The Inverted-V sign, Scrotal air
13 Abscess Gas
14 Pneumoretroperitoneum
RUQ/liver signs on supine AXR
There are 3 separate signs of free air around the liver as follows.

Pneumoperitoneum: Importance of Right Upper Quadrant Features

LESLIE MENUCK’ AND PAUL I. SIEMERS’
Am J Roentgeno! 127:753-756. 1976
 1. Anterior Subhepatic Space Free Air (RUQ sign 1)

Anterior subhepatic space

free air tends to be vaguely
linear in shape (arrowed). A
visible medial border of the
liver is often seen outlined
by fat. A careful examination
of this image (left) shows
the arrowed density to be air
density rather than fat
density.

The differentiation between

fat and air density becomes
Pneumoperitoneum: Importance of Right Upper Quadrant Features
easier with experience. This
LESLIE MENUCK’ AND PAUL I. SIEMERS’
Am J Roentgeno! 127:753-756. 1976 image of normal fat
surrounding the liver shows a
consistent density continuous
with the properitoneal fat
stripe.
 2. Doges Cap Sign (RUQ sign 2)

Doges Cap sign refers to free air in Morrison's

pouch. Morrison's pouch is normally a potential space
between the right kidney and the liver. This is a
particularly difficult sign of pneumoperitoneum for
several reasons. Firstly, it may be the only sign of
pneumoperitoneum and may be very subtle. Secondly,
it can be easily misinterpreted as gas in the
duodenum.

Gas in Morrison's pouch may have the following

features

 Triangular in shape
 concave medial border
 positioned inferior to the right 11th rib
 positioned superior to the right kidney

 This sign is known as

Doges Cap sign. The Italian
Doges wore this distinctively
shaped cap. Gas in Morrison's
pouch is only loosely shaped
Pneumoperitoneum: Importance of Right
Upper Quadrant Features
like a Doges cap and should not
LESLIE MENUCK’ AND PAUL I. SIEMERS’ be taken too literally. Bear in
Am J Roentgeno! 127:753-756. 1976
mind that the "triangle Sign"
was already taken!

 http://bp3.blogger.com/_iAsK5lmVXqM/Rpn6Q091zNI/AAAAAAAAAQE/
qDaIjgpsZa4/s320/doge.jpg
Morrison’s pouch free gas
demonstrated on supine
Radiographs typically show the
following Characteristics
1.Typically triangular shaped
2.The lower lateral corner is
commonly sharp
3.The lateral border is typically
concave and outlines the medial
border of the liver
4.It is positioned inferior to
the 11thrib
5.It is positioned superior to
the right kidney
3. Air Anterior to Ventral Surface of Liver(RUQ sign 3)

Air sitting against the

ventral surface of the liver
can be any shape and, as in
this case, is frequently
"geographical" in shape. The
liver is a homogenous organ
and should be homogenous in
density on plain film. If the
liver is seen to demonstrate
an uneven density,
pneumoperitoneum should be
considered.

Note also Rigler's sign

4. Decubitus Abdomen Sign

This patient is
in the left
lateral
decubitus
position. It is
conventional in
radiography to
mark the side
the side that
is up.

There is
evidence of
free air
between the
abdominal wall
and the liver
(white arrow).
There is also
evidence of
free fluid in
the peritoneum
(black arrow).
5. Rigler’s Sign on supine AXR

Rigler's sign is named after

Leo G. Rigler. The sign
refers to the appearance
of the bowel wall on plain
film when it is outlined by
intraluminal and
extraluminal air (arrowed).
The extraluminal air is free
peritoneal gas.
6. Falciform Ligament Sign

The falciform ligament connects

the anterior abdominal wall to
the liver. The ligament
continues to extend inferiorly
beyond the liver where it
becomes the round ligament
(white arrow). Given that the
falciform ligament is situated
against the anterior abdominal
wall, it is not surprising that it
becomes outlined with air in a
supine patient with free
abdominal gas.

This is an axial CT scan image of

a patient with
pneumoperitoneum. The free gas
is seen outlining the anterior
abdominal wall and several loops
of bowel. The arrowed
structure is the falciform
ligament surrounded by free
intraperitoneal gas.
 The falciform ligament sign is
almost never seen in isolation.
If there is enough free air to
outline the falciform ligament,
there is usually enough air to
also provide at least a Rigler's
sign. In this case(left), there is
a Rigler's sign as well as RUQ
signs. Note also bilateral
nephrostomy tubes insitu.

7. The ‘football’ sign

The football sign likens the massively air-
filled peritoneum to an American football.
To extend the simile a little further, the
falciform ligament has been likened to the
seam in the football, and the rarely seen
medial and lateral umbilical ligaments are
likened to the football laces.

This neonatal patient has massive

pneumoperitoneum and could reasonably be
said to display football sign. There is also
falciform ligament sign, Rigler's sign and
air in the scrotum.

http://shop.sportsmanswarehouse.com.au/images/product_images/16
60/foot001.jpg

John W. Rampton, MD
The Football Sign
(Radiology 2004;231:81-82.)RSNA, 2004
8. Continuous Diaphragm Sign

Another
manifestation of
massive
pneumoperitoneum
is the continuous
diaphragm sign.
Where there is
sufficient air
beneath the
diaphragm, the
continuous nature
of the diaphragm
is demonstrated.
Note that the left
and right
hemidiaphragms
contrasted by the
free gas appear as
a continuous
structure.

image source unknown

9. Double Bubble Sign

The double bubble sign

is an appearance of
subdiaphragmatic gas
under the left
hemidiaphragm in which
there are two
collections of
overlapping gas- one of
these collections is
subdiaphragmatic free
gas and the other is
normal gas within the
fundus of the stomach.
Note that the
diaphragm (black
arrow) is a thinner
walled structure than
the stomach wall (white
arrow). This distinction
is sometimes useful in
distinguishing between
the two structures.

Note also free

subdiaphragmatic gas
under the right
hemidiaphragm
10. The Cupola Sign.

The Cupola Sign refers to

an air accumulation
beneath the central tendon
of the diaphragm (white
arrows)

The term cupola comes

from a dome such as this
famous dome of the Duomo
in Florence.
11. Lesser Sac Gas

This image of
free gas has a
cupola sign
(white arrows)
and a lesser
sac gas sign
(black arrows).
The lesser sac
is positioned
posterior to
the stomach
and is usually a
potential
space. There is
free
connection
between the
lesser sac and
the greater
sac through
the foramen of
Winslow.
12. The Triangle Sign

The triangle sign

refers to small
triangles of free gas
that can typically be
positioned between
the large bowel and
the flank(black
arrow)
12. The Others
There are a number of other signs of pneumoperitoneum that are less commonly
seen. These signs are sufficiently rare to not warrant close examination. Equally,
for reasons of completeness, they have been included on this page.

Sign Notes Reference

Air under
Leaping
hemidiaphragm and http://www.thaigastro.com/book/file/Thai-Journal-
Dolphins
diaphragmatic muscle of-gastroenterology-vol-6-no-3-627306.pdf
Sign
slips visible
Air contrasted urachus.
Appears as vertical line
Urachus between bladder and
google
Sign umbilicus. Outline of
medial umbilical
ligament
" in infants the
“inverted V” is
undoubtedly caused by
The the large umbilical The “Inverted V” Sign of Pneumoperitoneum
John F. Bray, M.B., Ch.B., F.R.C.S. (Ed.),
Inverted arteries, in adults I
F.R.C.R.2
“V” Sign believe it is the inferior Radiology 1984; 151: 45-46
epigastric vessels that
produce the “inverted
V” sign.”
Air in the Air in the Fissure for
Fissure for the Ligamentum Teres.
the May appear in isolation. Radiology; 1991. 178: 489 - 492
Ligamentum Appears as a lucent
Teres vertical stripe over liver
Coronary
The coronary ligament
Ligament http://myweb.lsbu.ac.uk/dirt/museum/margaret/752-
is sited anterior to the
Outlined by 712-1000221.jpg
liver.
Air
Pneumo-gall Air in the gall bladder
google
bladder fossa outlining the gall
 bladder

13. Abscess Gas

This patient
has an abscess
(proven on CT).
The arrowed
bubbles of gas
are suspicious
in that they
are not clearly
contained
within normal
hollow
abdominal
viscus. If they
were, for
example,
contained
within the
colon, they
would tend to
be aligned in a
more linear
fashion and
may outline
normal
haustral
features.
14. Pneumoretroperitoneum

This patient has free air in

the retroperitoneal space. The
air is seen surrounding the
lateral border of the right
kidney (white arrow). There is
other evidence of free gas
including Rigler's sign.

If you are not confident that

the appearance is
pneumoretroperitoneum, you
can try an erect and decubitus
view to see if the gas moves.
If the gas is seen to move, it's
not in the retroperitoneum.

An axial CT scan image is

shown with air around the
right kidney (black arrow).
Case 1

This in-patient was referred

for chest radiography following
open mitral valve surgery.
There appears to be free air
under the right hemidiaphragm.
This was interpreted as
'colonic interposition'
(Chilaiditis sign) but I suspect
that it is a 'leaping dolphins
sign'. The appearance of septa
within the air collection under
the right hemidiaphragm is
probably outlining the costal
muscle slips of the
hemidiaphragm rather than
representing outline of bowel
wall.

There also appears to be a

negative 'silhouette sign' of
the liver (black arrow).

There is an azygous lobe (white

arrow).

There is a pleural effusion on

the left.
Quoted from
Morton A. Meyers
Dynamic radiology of the abdomen: normal and
pathologic anatomy
The lateral chest image
similarly demonstrates a
negative 'silhouette sign'
involving the liver (black
arrow).

There appears to be a triangle

of pleural fluid at the base of
an inferior accessory fissure.

There are three metallic rings

associated with the mitral
valve surgery.

There is loss of visualisation of

the left hemidiaphragm
associated with a left pleural
effusion.
Case 2

This 78 year old man presented

to the Emergency Department
with a history of abdominal
pain. He was examined and
referred for an acute
abdominal and chest X-ray
examination.

The PA chest projection image

shows some prominent
interstitial markings. There
appears to be gas under the
right hemidiaphragm. Note
that there is bowel gas
superimposed over the liver
suggesting colonic
interposition- a known cause of
false pneumoperitoneum. If
this appearance represented
pneumoperitoneum, you would
expect to see air-contrasted
liver.
The lateral chest projection
image demonstrates the
appearance again of air under
the right hemidiaphragm. The
is an associated air-fluid level.
This appearance is more likely
to indicate colonic interposition
than pneumoperitoneum.
Where there is a clinical
question of pneumoperitoneum,
a decubitius abdominal plain
film would be helpful.
Discussion

Pneumoperitoneum Pneumothorax Colonic Interposition

It is useful to be able to This appearance of colonic

distinguish between the interposition does bear
appearance of air under some similarity to the
This paient has a
the right hemi-diaphragm, appearance of
pneumothorax. The right
colonic interposition and pneumoperitoneum (above
hemidiaphragm contrasted
pneumothorax. left).
with air in the pleural
space resembles the liver
The black arrow identifies The white arrowed
contrasted with free air in
the aircontrasted liver. structure is probably a
the peritoneum(left)
The aircontrasted costal haustral marking and the
muscle slip is marked with black arrowed structure is
a white arrow diaphragmatic
Case 3

This is a 60 year old lady with

known Crohn's disease and
abdominal pain. She was
referred for an abdominal plain
film. The large bowel wall is
visible along both flanks. The
liver is also outlined by fat.
There is fat interposed
between the inferior border of
the liver and the hepatic
flexure of the colon (white
arrow)

There is properitoneal fat

contrasting the caecum (black
arrow)

These appearances are not

associated with
pneumoperitoneum. The
scattered air densities over
the liver probably represent
air within bowel.
Case 4

This is a supine bedside chest X-ray image post intubation. At a cursary glance
there may appear to be air under the right hemidiaphragm
This is in fact air above the diaphragm rather than under it. This patient has a
right sided pneumothorax with a deep sulcus sign. The pneumothorax is also visible
at the right lung apex (arrowed)
Discussion
Pneumoperitoneum is an important plain film finding. Untreated, pneumoperitoneum
has poor morbidity and mortality outcomes. Radiographers who are familiar with
the plain film appearances of pneumoperitoneum, particularly the supine
appearances, are more likely to undertake supplementary views to concusively
demonstrate the pathology. Moreover, they will also have the opportunity to report
the finding immediately to the referring doctor.