INTRODUCTION
Plain abdominal imaging remain
Pneumoperiteoneum is caused
by rupture of of hollow viscus
(Stomach, duodenum etc) with
exception of retroperitoneal
viscera
the choice of acute abdominal
Its commonly caused by
in emergency department.
perforation of stomach or
Pneumoperitoneum may be
duodenum, but other causes
detected with upright chest
such trauma, infection, and
radiograph; in patient with
surgery may found
critical illness supine decubitus
is preferred
 ETIOLOGY

Iatrogenic Spontaneous Traumatic Miscellaneous

Surgery Ulcer
Endoscopy perforation Blunt Coitus
NGT
NEC
Gynecology
Dialysis Post-
Penetrating
Tuberculosis partum
Resusciation
CLINICAL PRESENTATION

 Pain is typically acute, unremitting, and progressive

 Associated synptoms including
 Fever
 Nausea
 Vomitting

 Physical Examination shows diffuse tenderness typical that

of peritonitis
ROLE OF PLAIN RADIOGRAPHS AND CT IN THE
DIAGNOSIS OF PNEUMOPERITONEUM

Plain radiography
Plain radiography can demonstrate 55%-85% of patients with
pneumoperitoneum

This examinationis widely available,can be easily performed in

admitted patients, and is used to exclude major illness such as
perforated viscus, bowel obstruction, and foreign bodies ingestion.

Plain abdominal film is useful in the evaluation of the different types

of ileus (spastic ileus, hypotonic ileus, mechanical ileus, and paralytic
ileus).
CT scan
• CT is considered the most sensitive modality for the
diagnosis of pneumoperitoneum owing to its high spatial
resolution and capability to detect even the smallest
amount of free intraperitoneal air

• Thus, multidetector CT maybe superior to single helicalor

conventional CT for the diagnosis of gastrointestinal tract
perforation because many of these patients are in poor
condition and unable to perform prolonged breath holds
SIGNS OF PNEUMOPERITONEUM

?
There are many possible
imaging appearances of
pneumoperitoneum.
 On upright posteroanterior chest radiography,
pneumoperitoneum is visualized as a translucent
crescent or area below the diaphragm
o In supine abdominal radiograph, free peritoneal air may become visible
and, in various shapes and sizes,may be located in different positions.
o These free-air signs can be categorized into 4 groups:

Right- Peritoneal
Bowel-
upper- ligament- and other
related
quadrant related signs
signs
signs signs
 Rigler
Sign

• Rigler sign, also known as the bas-relief sign or the

double-wall sign, is the visualization of both sides of the
bowel wall, in a radiograph of the abdomen obtained with
the patient in the supine position
 Triangle
Sign

Free intraperitoneal air accumulating among 3 adjoining bowel loops or 2

bowel loops and the parietal peritoneum appearing as a triangular
radiolucency is called the triangle sign
Hyperlucent
Liver Sign

• In the supine radiographs, the blacker density of the

large intraperitoneal free gas anterior to the ventral
hepatic surface replacing the brightness of the
hepatic shadow is the sign called hyperlucent liver sign
 Anterior
Superior
Oval Sign

• This sign refers to a single or multiple oval, round, or pear- shaped

gas bubbles projected over the liver shadow.

The Visible
Gallbladder

• In supine abdominal radiograph, the gallbladder is seen as

homogeneous opacity because of surrounding free intraperitoneal
air.
 Fissure for
Ligament
Teres Sign
• This sign refers to a characteristic elongated area of hyperlucency that
represents intraperitoneal gas trapped within the fissure for the ligamentum
teres
Dolphin
Sign

• The undersurface of the long costal muscle slips of

the diaphragm that indented the adjacent air-filled
space in the right upper quadrant on supine films is a
sign of pneumoperitoneum
PERITONEAL LIGAMENT-RELATED
SIGNS

Falciform Ligament Sign

•A helpful sign of
pneumoperitoneum involving the
anterior superior peritoneal cavity is
visualization of the falciform
ligament

•the intraperitoneal free air may

outline the falciform ligament, which
is seen as a linear density situated
longitudinally within the right upper
abdomen
 Extrahepatic Ligamentum Teres Sign

•The ligamentum teres is another anterior peritoneal ligament that can be

visualized in plain radiographs.
•In supine radiographs, the extrahepatic ligamentum teres may be seen when
outlined by free air anywhere along the course of the ligament.
•On CT scan also this sign can be observed
 “Inverted V” Sign

•Free air outlining the lateral

umbilical ligaments makes these
structures visible in the lower
abdomen forming an
“inverted V” as it courses
inferiorly and laterally from the
umbilicus
 Transverse Mesocolon and
Root of Small Bowel
Mesentery Signs

Intraperitoneal free air can

determine the identification
of the transverse mesocolon
and the root of the small
bowel mesentery

Meso-Appendix Sign
Urachus Sign mesoappendix may be
observed in the supine
the urachus may be seen radiograph as a radio-
as a thin midline linear opaque linear stripe
structure in the lower directed from the cecum to
abdomen from the the middle of the abdomen
umbilicus to the dome of
the urinary bladder.
 OTHER SIGNS OF
PNEUMOPERITONEUM
Football sign

•It refers to a large oval radiolucency in the shape of an

American football producing a sharp interface with the
parietal peritoneum.
•The oval radiolucency seen in the football sign represents
massive pneumoperitoneum that distends the peritoneal
cavity.

Cupola Sign

•seen as an arcuate lucency overlying the lower thoracic

spine and projecting caudad to the heart in supine
radiograph.
•The term cupola is used to indicate the inverted cup-
shaped configuration of the lucency.
CONCLUSION
The diagnosis of hollow-organ perforation is based on the evidence of
pneumoperitoneum.
Although the upright and left decubitus projections are the most
sensitive views for the radiographic recognition of small collections of
free intraperitoneal air, the role of the supine projection should not be
minimized especially in the patients with critical illness.
the signs of pneumoperitoneum that can be observed on abdominal
plain films and on CT examinations.