Journal Reading

Oleh:
Dani Kartika Sari
Fathan Muhi Amrulloh
Wulan Noventi
Perceptor:
dr. Rasyidah, Sp.Rad

KEPANITERAAN KLINIK BAGIAN ILMU RADIOLOGI RUMAH SAKIT UMUM

DAERAH Dr. H. ABDUL MOELOEK
FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG
BANDAR LAMPUNG
2018
 Abstrack
 This study aimed to evaluate the sensitivities of the reported free air signs on
supine chest and abdominal radiographs of hollow organ perforation. We also
verified the value of supine radiographic images as compared with erect chest
and decubitus abdominal radiographs in detection of pneumoperitoneum.
 250 cases with surgically proven hollow organ perforation were included. 527
radiographs were retrospectively reviewed on the picture archiving and
communication system.
 Upper gastrointestinal tract perforation was proven in 91.2%; small bowel
perforation, in 6.8%; and colon perforation, in 2.0%. The positive rate of free air
was 80.4% on supine KUB(supine abdominal radiographs), 78.7% on supine CXR
(supine chest radiographs), 85.1% on erect CXR, and 98.0% on left decubitus
abdominal radiograph. Anterior superior oval sign was the most common
radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air
signs ranged from 0% to 30.4%.
 Most free air signs on supine radiographs are located over the right upper
abdomen. Familiarity with free air signs on supine radiographs is very important
to emergency physicians and radiologists for detection of hollow organ
perforation.
Introduction

 Hollow organ perforation is always life threatening and usually

needs the urgent surgical intervention. Detection of the
intraperitoneal free gas is valuable in the diagnosis of hollow
organ perforation.
 Computed tomography is the most sensitive examination to
visualize the extraluminal air and plain supine radiographs cannot
always detect the presence and extent of an abnormal lucency,
the value of the plain supine radiographs to diagnose
intraperitoneal free air is usually ignored by the emergency
physicians in modern times
 However, the plain radiography is still the fastest and most
efficient and cheapest imaging examination for detecting
intraperitoneal free air at emergency department
 On plain radiographs, very small amounts of extraluminal free air
still can be visualized
 Metods
Two hundred seventy-one cases with any sex, any age, and
surgically proven hollow organ perforation from December 2000
to August 2007 were included in this study by electronic search of
the medical registry database of our institute.

Excluding:
-cases without available images
-poor image quality
-intervals between radiographs and operation longer than 3 days

250 cases were used for ourstudy

Metods

 527 radiographs of these cases were retrospectively

reviewed on the picture archiving and
communication system for detection of free air.
Including:

- 184 supine abdominal radiographs (KUB)

- 150 supine chest radiographs (CXR)
- 94 erect CXR
- 99 left decubitus abdominal
radiographs.
 Medical charts were reviewed for the operative
findings of perforation sites, which were categorized
into 3 groups of upper gastrointestinal tract (UGI), small
bowel, and colon perforations. The underlying
etiologies were also recorded.
 The variable free air signs on the supine radiographs
reported in the literature were evaluated for every
case, including Rigler sign, hyperlucent liver sign,
falciform ligament sign, inverted V sign, urachus sign,
anterior superior oval sign, fissure for ligament teres
sign, doge cap sign, football sign, cupola sign, hepatic
edge sign, triangle sign, and dolphin sign
 These free air signs were categorized into 4 groups:
bowelrelated signs, right-upper-quadrant (RUQ) signs,
peritoneal ligament-related signs, and other signs
 Definitions of radiographic signs
of pneumoperitoneum
1. Bowel Related-sign

Rigler sign Triangle sign

Free intraperitoneal air
accumulating among
also known as the bas-
3 adjoining bowel
relief sign or the
loops or 2 bowel loops
double-wall sign, both
and the parietal
sides of the bowel wall
peritoneum appearing
can be visualized on a
as a triangular
supine KUB
radiolucency is called
the triangle sign
Fig. 1 A 1-year-old female subject with
cecal perforation due to chronic
inflammation. The KUB shows Rigler
sign (broken arrows), falciform
ligament sign (straight arrows), and
cupola sign (arrowheads).
Fig. 2 A 28-year-old female
subject with perforated
duodenal ulcer. The KUB shows
triangle sign (broken arrows) and
fissure for ligament teres sign
(straight arrows).
 2. RUQ-sign

Hyperlucent liver Anterior superior Fissure for ligament

sign oval sign teres sign
• On the supine • This sign refers to • Visualization of
radiographs, the a single or the extrahepatic
blacker density of multiple oval, part of ligament
the large round, or pear- teres on supine
intraperitoneal shaped gas radiographs is
free gas anterior bubbles called fissure for
to the ventral projected over ligament teres
hepatic surface the liver shadow sign
replacing the
brightness of the
hepatic shadow
is the sign called
hyperlucent liver
sign
 2. RUQ-sign

Doge cap sign Hepatic edge sign Dolphin sign

• This sign refers to • An oblong saucer or • The undersurface of

triangle-shaped cigarshaped the long costal muscle
freeair accumulated collection of free air slips of the diaphragm
in Morison pouch on may be seen in the that indented the
supine abdominal subhepatic space adjacent airfilled
films with its long axis space in the RUQ on
directed supine films is a sign of
superomedially pneumoperitoneum
following the liver
contour
Fig. 3 An 83-year-old male
subject with perforated duodenal
ulcer. The CXR shows hyperlucent
liver sign (broken arrows) and
dolphin sign (straight arrows).

Fig. 4 A 68-year-old male

subject with proximal jejunum
perforation due to ischemic
bowel disease. The CXR shows
anterior superior oval sign
(broken arrows) and left
anterior superior oval sign
(straight arrows).
Fig. 5 A 76-year-old male subject
with pylorus perforation. The KUB
shows doge cap sign (arrows).
Fig. 6 A 77-year-old male
subject with Billroth II
anastomosis perforation. The
KUB shows hepatic edge sign
(broken arrows) and football
sign (straight arrows).
 RUQ signs

Hyperlucent liver sign.

• On 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

Fissure for ligament teres sign.

• Visualization of the extrahepatic part of ligament teres on supine

radiographs is called fissure for ligament teres sign

Doge cap sign.

• This sign refers to triangle-shaped free air accumulated in Morison

pouch on supine abdominal films.
Hepatic edge sign.

•An oblong saucer or cigarshaped collection of free air may be seen in the
subhepatic space with its long axis directed superomedially following the liver
contour.

Dolphin sign.

•The undersurface of the long costal muscle slips of the diaphragm that
indented the adjacent airfilled space in the RUQ on supine films is a sign of
pneumoperitoneum.

Falciform ligament sign.

•The intraperitoneal free air may outline the falciform ligament, which is seen as
a linear density situated longitudinally within the right upper abdomen.

Inverted V sign.

•An inverted “V” may be seen over the pelvis on the supine films caused by the
2 lateral umbilical ligaments outlined by free air

Urachus sign.

•When pneumoperitoneum occurs, the urachus may be seen as a thin midline

linear structure in the lower abdomen from the umbilicus to the dome of the
urinary bladder
 Other signs
Football sign.
• It refers to a large oval radiolucency in the shape of an
American football producing a sharp interface with the parietal
peritoneum on a supine abdominal radiograph

Cupola sign.
• The cupola sign, also called saddlebag or moustache sign, is
seen as an arcuate lucency overlying the lower thoracic spine
and projecting caudad to the heart on supine radiograph

Left-sided anterior superior oval sign.

• We defined a single or multiple oval, round, or pear-shaped free air projected
over left upper quadrant abdomen as “leftsided anterior superior oval sign”
Subphrenic radiolucency.
• Radiolucency appeared beneath the diaphragm, either right or left side on the
supine CXR, was defined as “subphrenic radiolucency”
Result
Recently, many groups have omitted the routine administration
of highattenuation oral contrast material because

patients with SBO are contrast material rarely

nauseated and may opacifies the bowel just
vomit, potentially leading proximal to the transition
to point in a high-grade
aspiration obstruction; and

the low-attenuation fluid and gas

within the obstructed lumen
provide excellent contrast relative
to the normally enhancing bowel
wall, which is obscured by high-
attenuation oral contrast material.
CT Finding

Multidetector CT is the single

best imaging tool for suspected
SBO. Multidetector CT has a
sensitivity and specificity of 95%
for the diagnosis of high-grade
SBO and is less accurate in
partial obstruction (4,6–8). As
with radiography, the hallmark is
dilated (. 2.5 cm) proxima small
bowel with decompressed distal
small bowel and colon (Table 2,
Fig 7) (15). Air-fluid levels will be
present and a string of beads
sign may be identified.
 Discussion
 Gastrointestinal tract perforation can be caused by a variety of
reasons, including peptic ulcer disease, trau- matic event, foreign
body, appendicitis, diverticular disease, inflammatory bowel
disease, abscess, neoplasm, and iatrogenic factors
 In this study, the incidence of pneumoperitoneum with UGI
perforation is 91.2%, and peptic ulcer diseases are the most
common cause in 96.5% of these patients. consistent with
previous studies.
 gastro- intestinal tract perforation has been reported to cause
pneumoperitoneum from 40% to 80% of patients
 peptic ulcer diseases are the reasons of pneumoperitoneum in
about 90%
 In this research, small bowel perforation resulted in 6.8% of
pneumoperitoneum, and intestinal obstruction-induced perforation
accounts for the most common etiology in approximately 47.1%.
 In previous report, the incidence of the small bowel perforation was 20%. The
perforation of colon only occurred in 2.0% in our study, whereas the
incidence was reported as 34% in the literature
 that such a difference might be due to the small case number of our study.
 In our study, anterior superior oval sign was the most common sign of
pneumoperitoneum on the supine radio- graphic images, which was present
in 44.0% on supine KUB and 34.0% on supine CXR.
 The second most frequent sign was hyperlucent liver sign, which appeared in
30.4% on supine KUB and 27.3% on supine CXR.
 We categorized the free air signs to 4 groups: bowel-related signs, RUQ signs,
peritoneal ligament-related signs, and other signs.
 The overall sensitivity of the RUQ free air signs, including
hyperlucent liver sign, anterior superior oval sign, fissure for
ligament teres sign, doge cap sign, hepatic edge sign, and
dolphin sign.
 The RUQ free air signs are the most frequent signs of
pneumoperitoneum on supine radiographs. This location is the
important place to look for small accumulations of intraperitoneal
free gas
 Our study showed no significant correlation between free air signs
and perforation sites. Therefore, free air signs on the supine KUB
cannot be used to predict the peroration sites of the
gastrointestinal tract.
 The higher sensitivity of free air detection was mainly
attributed to the recognition of anterior superior oval sign.
Familiarity with the various signs of intraperitoneal free air
on supine radiographic images could lead to more
accurate diagnosis of hollow organ perforation.
 In the literatures, taking radiographic images with
different positions can result in different sensitivities for the
pneumoperitoneum
 Either erect CXR or left decubitus abdominal radiographs
have been thought as the standard plain film projections
to detect intraperitoneal free gas.
 In our study these 2 kinds of radiographic images are
more sensitive than supine KUB and supine CXR
 There is no significant difference between the sensitivities of
supine KUB and supine CXR for free air detection.
 However, the quality of supine CXR is always whiter than that
of supine KUB, so that it might increase the difficulty for
physicians to survey the pneumoperitoneum rapidly at ED,
especially when there is a small amount of intraperitoneal free
gas. In our experience, supine KUB is superior to supine CXR
because the hollow organ perforation is highly suspected.
 The result means that the 2 kinds of radiographic films are
equally effective in diagnosing hollow organ perforation.
Limitation

small case number of our study.

this is a retrospective study with small population. There might

be inherent bias in interpreting these cases for free air and
statistical analysis.

The imaging quality of the radiographs also influences the

judgment of the viewers, such as overexposure or underexposure,
inappropriate positioning, and inadequate field of view.
 Conclusions

Radiologic studies play an important role in the diagnosis of pneumoperitoneum.

Most free air signs on supine radiographs are located over the right upper
abdomen, with anterior superior oval sign as the most common sign.

The demonstration of intraperitoneal free air on the radiographic images is often

the initial clue to diagnose hollow organ perforation in an ED.

Supine CXR is as sensitive as supine KUB for free air detection.

Only if supine radiograph is incon- clusive while hollow organ perforation is still suspected
clinically, left decubitus abdominal radiograph or erect CXR should be taken.