William Herring, M.D.

© 2002

Recognizing Free Air

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 Remember

Air will rise to whatever is

the highest part of the
abdomen
The 3 Signs of Free Air

 Air beneath diaphragm

 Both sides of bowel wall
 Falciform ligament sign
Air beneath
the diaphragm
forms a
crescentric
lucency seen
best on the
right side over
the liver

ERECT
Air on both sides of the bowel
wall (Rigler’s sign). Normally
(see below) you do not see the
bowel wall as a discrete line.

Normal
Air over the
convexity of the
liver on a supine
view outlines the
Falciform ligament,
which is usually
invisible.

Falciform Ligament Sign

These are the Causes of Free Air

 Rupture of a hollow viscus

 Perforated ulcer
 Perforated diverticulitis
 Perforated carcinoma
 Trauma or instrumentation
 Post-op 5–7 days
 NOT perforated appendix
Which of the following
patients has free air?

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Does this patient have free air?

Yes

No

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Does this patient have free air?

Yes

No

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Does this patient have free air?

Yes

No

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Does this patient have free air?

Yes

No

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Correct
There is Free Air

 Both sides of the

bowel wall (the
stomach) are visible

Go Ahead
Correct
There is No Free Air
The stomach is dilated, but
both sides of the stomach
wall are not visualized

Go Ahead
Correct
There is No Free Air
None of the signs of free air
is present here

Go Ahead
Correct
There is Free Air
Both sides of the bowel
wall are visualized here.

Go Ahead
Wrong
Look Again

 Remember to look for the 3 signs of free

air
 Air beneath diaphragm
 Both sides of bowel wall
 Falciform ligament sign

Go Back
Congratulations, You Graduate

I know my
Free Air