Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

Rigler and Cupola Signs

Santiago Martínez-Jiménez, MD

Selected Images Hide Images

AP supine chest radiograph of a
patient with a large
pneumoperitoneum due to hollow
viscus perforation shows
visualization of both sides of the
bowel walls in the right upper
quadrant (i.e., Rigler sign) and
a curvilinear lucency from gas
collected along the central tendon of
the diaphragm (i.e., cupola sign)
.
Coned-down PA chest radiograph
shows a large right upper quadrant
pneumoperitoneum. Note that gas
outlines both sides of the bowel wall
due to the presence of both
intra- and extraluminal gas.
AP chest and abdomen radiograph
of a neonate with complicated acute
necrotizing enterocolitis shows a
large pneumoperitoneum that
manifests as a subtle lucency over
the abdomen (sometimes referred
to as the football sign due to
its morphology). Note the subtle
Rigler sign .
Left lateral decubitus radiograph of
the same patient shows free
peritoneal gas outlining the
liver surface and visualization of the
bowel wall (i.e., Rigler sign) in
the right mid abdomen.

Additional Images

AP chest radiograph of a patient
with a perforated gastric ulcer
shows a large pneumoperitoneum
that outlines the inferior surface of
the right hemidiaphragm , the
Rigler sign and the cupola sign
. sign.
Coned-down PA chest radiograph
shows a large left upper quadrant
pneumoperitoneum. Both sides of
the bowel wall are visible
outlined by intraluminal and
extraluminal gas, the so-called Rigler
Coronal NECT of the abdomen of
the same patient shows visualization
of the both sides of the bowel walls
of multiple bowel loops outlined
by both intra- and extraluminal gas.
Normally, only the intraluminal
surface of the bowel wall is outlined
by air and therefore visible.
AP chest radiograph shows a large
pneumoperitoneum that manifests
with gas under the diaphragm. The
midline infradiaphragmatic gas
collection exhibits a curvilinear
morphology with a well-defined
superior border and an ill-defined
inferior border, consistent with the
cupola sign. The Rigler sign may be
absent in spite of the presence of a
large pneumoperitoneum.

KEY FACTS

Terminology
Rigler sign: Pneumoperitoneum that allows visualization of both sides of the bowel wall
Cupola sign: Pneumoperitoneum accumulated under central tendon of diaphragm
Imaging
Chest radiography
Normally, only luminal surface of bowel wall is outlined by gas
Rigler sign: Discernible bowel wall, outlined by luminal gas (inner wall) and free peritoneal gas (outer wall)
Cupola sign: Arcuate lucency over lower thoracic spine, caudal to heart; well-defined superior margin, ill-defined inferior
border; often superiorly concave
Useful in supine patients, as infradiaphragmatic gas may not be evident
When in doubt, upright or left lateral decubitus radiography may help confirm pneumoperitoneum
 Top Differential Diagnoses
Pneumomediastinum
Continuous diaphragm sign (tends to be linear) may mimic cupola sign (tends to be curved)
Normal bowel loops
Adjacent bowel loops may mimic Rigler sign
Gas in transverse colon, lesser sac, or pericardium may mimic cupola sign
Oral contrast
Residual contrast from recent CT may increase apparent bowel wall density and may simulate Rigler sign
Mach bands: Optical illusion that exaggerates contrast between adjacent structures of differing density
Diagnostic Checklist
Identification of pneumoperitoneum may be challenging in supine patients
Consider upright or left lateral decubitus radiography for confirmation

SELECTED REFERENCES

1. Kloth C et al: Pathognomonic imaging signs in abdominal radiology. Abdom Radiol (NY). 45(2):576-86, 2020
2. Indiran V et al: Rigler sign. Abdom Radiol (NY). 42(10):2588, 2017
3. Pinto A et al: Spectrum of signs of pneumoperitoneum. Semin Ultrasound CT MR. 37(1):3-9, 2016
4. Simpson J et al: Rigler on the roof. Rigler's sign. Gut. 57(6):798, 836, 2008
5. Marshall GB: The cupola sign. Radiology. 241(2):623-4, 2006
6. Lewicki AM: The Rigler sign and Leo G. Rigler. Radiology. 233(1):7-12, 2004
7. Ly JQ: The Rigler sign. Radiology. 228(3):706-7, 2003
8. Zylak CM et al: Pneumomediastinum revisited. Radiographics. 20(4):1043-57, 2000
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