Advanced Emergency Nursing Journal

Vol. 40, No. 2, pp. 87–93

Copyright 
C 2018 Wolters Kluwer Health, Inc. All rights reserved.

Imaging
Column Editor: Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN

Pneumoperitoneum
Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN

Abstract
Pneumoperitoneum, usually seen as free air under the diaphragm, is a finding that can be seen on
plain abdominal radiographs, signifying a leakage of air, usually from a perforation in the gastroin-
testinal tract. There are several other potential pathways from other body compartments for air to
enter the abdominal cavity. Pneumoperitoneum does not always signify bowel rupture, as it can also
result from pneumomediastinum and pneumothorax, and in patients who are being mechanically
ventilated. Patient history and physical examination can assist in a preliminary diagnosis before di-
agnostic imaging. Plain chest/abdominal radiograph or computed tomographic scan of the abdomen
can be diagnostic of pneumoperitoneum. Surgical versus nonsurgical conservative observation is
determined on the basis of the cause and amount of free air. Key words: abdominal free air, benign
pneumoperitoneum, free air under diaphragm, intraperitoneal air, mottled air sign, pneumomedi-
astinum, pneumoperitoneum, retroperitoneal air, Rigler’s sign, tension pneumoperitoneum

TERMS PATIENT HISTORY

Pneumoperitoneum: Free air within the
peritoneal cavity
Benign pneumoperitoneum: Asymptoma-
tic free intra-abdominal air in the abd-
omen
Tension pneumoperitoneum: Free intra-
peritoneal air in the abdomen under pres-
sure that compromises blood flow and
visceral function
Author Affiliation: School of Nursing and Health
Sciences, Robert Morris University, Moon Township,
Pennsylvania.
Medical illustrations by Bethany Barbis, Media Arts Stu-
dent, Robert Morris University.
Disclosure: The author reports no conflict of interest.
Corresponding Author: Denise R. Ramponi, DNP,
FNP-C, ENP-BC, FAEN, FAANP, CEN, School of Nursing
and Health Sciences, Robert Morris University, Scaife
Hall, 6001 University Blvd, Moon Township, PA 15108
(dramponi@comcast.net).
DOI: 10.1097/TME.0000000000000189
Salient points of the patient history to be col-
lected include any concurrent medical con-
ditions such as gastric or duodenal ulcer, ir-
ritable bowel disease, and diverticulitis that
can lead to pneumoperitoneum from gastroin-
testinal (GI) perforations. Recent surgical pro-
cedures, mechanical ventilation, trauma ex-
posure, or other invasive procedures can lead
to pneumoperitoneum. Sexual history in sex-
ually active women is an important part of
the patient’s history, as air can enter the peri-
toneum via the vaginal pelvic route during
sexual intercourse.
PHYSICAL EXAMINATION
“Benign pneumoperitoneum” is a term uti-
lized when a patient is asymptomatic but has
evidence of free intra-abdominal air. Clinical
manifestations of benign pneumoperitoneum

87

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 88
can include abdominal distention, soft ab-
domen, but no signs of peritonitis or abdom-
inal wall redness. Patients with pneumoperi-
toneum that extends to pneumomediastinum
often display dyspnea, chest, and neck pain,
with subcutaneous emphysema in the cervi-
cal and neck soft tissues. Patients with hol-
low viscus perforation have decreased or no
bowel sounds, signs of peritonitis, and often
progresses to redness and swelling of the ab-
dominal wall.
Tension pneumoperitoneum occurs in pa-
tients when free intra-abdominal gas is un-
der pressure, compromising blood flow and
visceral function. This massive accumulation
of air pressure compresses the inferior vena
cava, resulting in decreased venous return
and reduced cardiac output. These patients
often have severe abdominal pain, abdominal
tenderness, and abdominal distension. When
severe, patients may present with dyspnea,
venous congestion signs such as skin mot-
tling or edema, and signs of aortic occlusion
such as loss of peripheral pulses in the lower
extremities.
CAUSES
Pneumoperitoneum often results from a per-
foration in the GI tract, such as a ruptured
hollow viscus. Once the diagnosis of pneu-
moperitoneum is made, a search for the
source is needed. Perforation of the GI tract
can occur following colonoscopy, barium en-
ema, or percutaneous endoscopic gastros-
tomy tube placement. Mayo Clinic (Farley
et al., 1997) estimated large bowel perforation
at 0.075% incidence following colonoscopy in
a retrospective study of 57,028 colonoscopy
procedures. Patients at higher risk of perfora-
tion include those with diverticulosis, rectal
disease, cancer, inflammatory bowel disease,
or stricture. Crohn’s disease has an incidence
of 1% perforation of the small bowel and is
the most common cause of small bowel per-
foration in the Western world (Greenstein,
Mann, Sachar, & Aufses, 1985; Greenstein
et al., 1987). Barium sulfate leakage into the
peritoneum can cause a progressive lethal
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Advanced Emergency Nursing Journal
peritonitis, therefore requiring aggressive sur-
gical intervention to remove any intraperi-
toneal barium. Pneumoperitoneum can also
be found on imaging for 7 days after an
abdominal surgical procedure, including la-
paroscopy, and may last for up to 4 weeks
(Gayer et al., 2000).
Pneumatic enema is often used for ileo-
cecal intussusception reduction. An adverse
sequela of tension pneumoperitoneum
can occur following this procedure when
excessive air is insufflated into the rectum
to reduce the intussusception, causing a
perforation leading to pneumoperitoneum.
Intraperitoneal or retroperitoneal free air can
have respiratory-associated causes such as
mechanical ventilation-induced barotrauma,
bronchial asthma, and pneumothorax
through pleural and diaphragmatic defects.
Incidence of ventilation-induced pneu-
moperitoneum is estimated at 7% (Henry,
Ali, Banks, & Dais, 1986). It has also been
noted that there is an open access between
the vagina and the abdomen. Pneumoperi-
toneum can result from pelvic manipulation
or insufflation, and sexual intercourse. More
than 90% of pneumoperitoneum are caused
by visceral perforation (Duan et al., 2017).
Perforated viscus can include perforation
from peptic ulcer, stomach, small intestine, or
colon.
BODY COMPARTMENTS
There are various potential pathways for air
movement along the fascial planes of the
body from one compartment to the next.
The compartments of the body are anatom-
ically connected, allowing air movement via
the fascial planes with differences in pres-
sure (see Figure 1). Air can spread from one
compartment to the adjacent compartment
via an opening and a pressure gradient (see
Figure 2). Air can dissect from the medi-
astinum into the soft tissues of the neck, re-
sulting in subcutaneous emphysema in the
soft tissues. Air can dissect through the pleu-
ral space in the chest cavity into the abdomen
with defects in the diaphragm. Air can dissect
 April–June 2018 r Vol. 40, No. 2
Figure 1. Compartments or cavities of the body.
Illustration is the original artwork by Bethany
Barbis.
along the perivascular tissue from the medi-
astinum into the abdomen.
RADIOGRAPHIC STUDIES
One of the most common findings of pneu-
moperitoneum on a plain radiograph, such
as kidneys, ureters, and bladder (KUB) film
of pneumoperitoneum, is free air under the
Figure 2. Examples of how air can dissect from
one compartment to adjacent compartments via air
pressure gradients to cause pneumoperitoneum.
Illustration is the original artwork by Bethany
Barbis.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pneumoperitoneum 89
diaphragm (see Figures 3 and 4). Another
finding of pneumoperitoneum includes air on
both sides of the bowel wall known as Rigler’s
sign (see Figures 5 and 6). Rigler’s sign is also
referred to as the “double-wall sign,” as air is
seen on both the intraluminal and peritoneal
sides of the intestinal wall. Other findings on
plain radiographs can include gas outlining
the falciform ligament and air along the psoas
muscles (Pollard & Entzian, 2005). If the pa-
tient is unable to stand for a KUB radiograph,
a left lateral decubitus radiograph can be uti-
lized, demonstrating free air rising to the sur-
face of the abdomen as the patient is lying on
his or her side.
Figure 3. Pneumoperitoneum. Plain radiograph of
the right upper quadrant shows a tiny streak of air
under the diaphragm due to a pneumoperitoneum.
From Pneumoperitoneum Imaging, by A. N.
Khan and M. Chandramohan, 2016, Medscape.
Retrieved from https://emedicine.medscape.com/
article/372053-overview. Used with permission.
 90
Figure 4. Pneumoperitoneum. Upright chest ra-
diograph shows a large collection of air under
both hemidiaphragms due to perforated duodenal
ulcer. From Pneumoperitoneum Imaging, by A.
N. Khan and M. Chandramohan, 2016, Medscape.
Retrieved from https://emedicine.medscape.com/
article/372053-overview. Used with permission.
Perforations to retroperitoneal hollow orga-
ns can also cause free air in the retroperitoneal
space. Organs in the retroperitoneal space
include a portion of the esophagus, the
duodenum, ascending and descending
colon, rectum, and the urinary tract system.
Retroperitoneal infections, such as emphy-
sematous pyelonephritis, can produce gas in
the retroperitoneal space, creating a “mottled
air sign” demonstrated by a cluster of small
numerous air bubbles on plain abdominal
radiograph (Wang, Wang, Chow, Chiu, &
Yang, 2004; Yokomuro et al., 2004). Free
air in the retroperitoneal space is character-
istically seen by a thread like radiolucency
surrounding the perforated organ (Yokomuro
et al., 2004).
COMPUTED TOMOGRAPHY
Despite plain radiographs often providing the
diagnosis of pneumoperitoneum, computed
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Advanced Emergency Nursing Journal
Figure 5. Clear definition of both the inner and
outer walls of the bowel—Rigler’s sign. From
“Acute Onset of Abdominal Pain in a 76-Year-
Old Man,” by G. Dehadrai, 2017, Medscape.
Retrieved from https://reference.medscape.com/
viewarticle/727508. Used with permission.
tomography (CT) has a higher sensitivity of
92% compared with 74% for plain radiography
for the presence of free intraperitoneal air
(Catalano, 1996). A CT scan with oral con-
trast provides opacity of the bowel lumen to
identify a bowel leak in the GI tract. Perfora-
tions in the distal small bowel or large bowel
can take several hours before the oral contrast
opacifies the bowel lumen. This time lapse
can be difficult, particularly in a very ill pa-
tient. A CT scan utilizes radiation and is more
expensive than plain radiographs and ultra-
sound scan. Sensitivity of a CT scan has much
lower ranges from 33% to 94% in identifying
small bowel perforations (Grassi, Pinto, Rossi,
& Rotondo, 1998; Scherck, Shatney, Sensaki,
& Selivanov, 1994). The small bowel is of-
ten collapsed; thus, it does not contain much
air or liquid, which makes CT scan diagnosis
of small bowel perforation more difficult. A
CT scan with oral contrast has a 100% sen-
sitivity for perforations of the lower GI tract
including the stomach, duodenum, and colon
 April–June 2018 r Vol. 40, No. 2
Figure 6. Clear definition of both the inner wall
and outer wall of the bowel (the Rigler sign) and
the presence of free air under the right hemidi-
aphragm demonstrate pneumoperitoneum. From
“Acute Onset of Abcominal Pain in a 76-Year-Old
Man” by G. Dehadrai, 2017, Medscape. Retrieved
from http://reference.medscape.com/viewarticle/
727508. Used with permission.
(Catalano, 1996). A CT scan with oral contrast
would demonstrate extravasation of contrast
into the abdomen if perforation of the GI tract
exists (see Figures 5 and 6). A CT scan is able
to differentiate air in the retroperitoneal space
from other compartments (see Figures 7
and 8).
ULTRASONOGRAPHY
Ultrasonography is readily available at most
centers and is commonly used to look for per-
forations. It is particularly advantageous in
those patients in whom radiation should be
avoided such as pregnant patients, pediatric
patients, and patients of childbearing age. It
can be used to diagnose and monitor free air
in the abdomen with the advantage of no ra-
diation exposure (Nurnberg et al., 2007). Ul-
trasound scan is also less costly to perform
than a CT scan. It is generally not considered
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Pneumoperitoneum 91
Figure 7. Pneumoperitoneum. Contrast-enhanced
axial computed tomographic scan through the
liver shows a collection of air anterior to the
liver. Also note the air surrounding the gall-
bladder and the leakage of water-soluble con-
trast material from a perforated duodenal ulcer.
From Pneumoperitoneum Imaging, by A. N.
Khan, and M. Chandramohan, 2016, Medscape.
Retrieved from https://emedicine.medscape.com/
article/372053-overview. Used with permission.
the investigational method of choice, as gas
is a reflector that does not allow the transmis-
sion of ultrasound waves. The gas within the
bowel wall also can prevent an accurate in-
terpretation (Goudie, 2013). Ultrasound scan
can identify free intra-abdominal fluid and in-
flammatory masses that cannot be seen on
plain radiographs. The disadvantage of ultra-
sonography is that it is operator dependent.
Ultrasonography is also quite limited to di-
agnose pneumoperitoneum in those patients
who are obese or have large amounts of
intra-abdominal gas (Stanford, McGonigal, &
Weigelt, 1999).
INTERVENTIONS
Hospital Admission
A patient’s clinical examination and diagnos-
tic findings will guide whether the patient
needs surgical management or can be conser-
vatively managed. Patients who may be con-
sidered for conservative treatment include
patients with perforations that are asymp-
tomatic, perforations without extravasation,
and those diagnosed within 8 hr of injury with
 92 Advanced Emergency Nursing Journal

Figure 8. Pneumoperitoneum. Nonenhanced axial computed tomographic scan through the tip of the liver
shows leakage of oral contrast material (arrows) from a perforated gastric ulcer. From Pneumoperitoneum
Imaging, by A. N. Khan and M. Chandramohan, 2016, Medscape. Retrieved from https://emedicine.
medscape.com/article/372053-overview. Used with permission.

mild symptoms (Pollard & Entzian, 2005).
The majority of nonsurgical pneumoperi-
toneum are caused by mechanical ventilation
(Mularski, Sippel, & Osborne, 2000). These
patients are intubated and often have multiple
comorbidities, including immunosuppression
and high-dose steroid use. This can lead to
peritonitis and sepsis. Those patients should
be admitted to the hospital, ordered bowel
rest, intravenous fluids, intravenous antibi-
otics, and close observation. These patients
should be monitored for changes in vital signs,
leukocytosis, and return of bowel function
and resolution of abdominal pain.
Surgical Intervention
When CT scan with oral contrast demon-
strates extravasation of contrast, operative in-
tervention is indicated and surgery should be
urgently consulted.
CONCLUSION
Pneumoperitoneum is often caused by a rup-
tured hollow viscus that can occur anywhere
in the lower GI tract, but it is not always
caused by bowel perforation. Air in the peri-
toneal space can result from a variety of
sources including laparoscopy, gas-forming
bacterial infection, and sexual intercourse.
The patient’s history of conditions such as gas-
tric or duodenal ulcer, irritable bowel disease,
diverticulitis, or recent surgery can make the
patient at higher risk for pneumoperitoneum.
Patient symptoms can range from abdominal
distention with decreased bowel sounds to
severe abdominal pain, lower extremity mot-
tling, and loss of pulses. Pneumoperitoneum
can be diagnosed on plain KUB or lateral decu-
bitus radiographs with the finding of free air
in the abdomen. Oral contrast CT scan is the
primary diagnostic tool to determine whether
surgery is necessary. It may take several hours
for the contrast to enter the distal small bowel
and large intestine if that is the area of bowel
perforation Mechanical ventilation is the most
common cause of nonsurgical pneumoperi-
toneum. Surgical consult is often necessary as
operative intervention is indicated in 85%–
95% of pneumoperitoneum cases (Mularski
et al., 2000).
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