Extraluminal Gas in the Abdomen

SIGNS OF FREE INTRAPERITONEAL AIR

There are three major signs of free intraperitoneal air, which they are
most commonly seen:
■ Air beneath the diaphragm
■ Visualization of both sides of the bowel wall
■ Visualization of the falciform ligament
 The most common causes of free air are perforated peptic ulcer,
trauma (whether accidental or iatrogenic), perforated diverticulitis,
perforated appendicitis, and perforation of a carcinoma, usually of the
colon
AIR BENEATH THE DIAPHRAGM
Air will rise to the highest part of the abdomen.
In the upright position, free air will usually reveal itself
under the diaphragm
 Free air beneath the diaphragm.
There are thin crescents of air beneath both
the right (solid white arrow) and left (dotted
white arrow) hemidiaphragms representing
free intraperitoneal air.
 Although free air is best demonstrated on computed tomography (CT) scans of the
abdomen because of its greater sensitivity in detecting very small amounts of free air

Free air seen on CT scan of the abdomen.

Axial CT scan of the upper abdomen
performed with the patient supine shows
free air anteriorly (white arrows).
Free intraperitoneal air will normally rise
to the highest point of the abdomen.
 If the patient is unable to stand or sit upright, then a view of the
abdomen with the patient lying on the left side taken with a horizontal
x-ray beam may show free air rising above the right edge of the liver
 Left lateral decubitus view showing free air.
Close-up of the right upper quadrant in a patient lying on the left side in the left lateral
decubitus position shows a crescent of air (dotted white arrows) above the outer edge of
the liver (black arrow), beneath the right hemidiaphragm (solid white arrow).
VISUALIZATION OF BOTH SIDES
OF THE BOWEL WALL
In the normal abdominal radiograph, visualize only the
air inside the lumen of the bowel, not the wall of the
bowel itself.
The ability to see both sides of the bowel wall is a sign of free intraperitoneal
air called Rigler sign

Rigler sign.
When air fills the peritoneal cavity, both sides of the
bowel wall will be outlined by air (white arrows)
making the wall of the bowel visible as a discrete line.
This is known as Rigler sign and indicates the
presence of a pneumoperitoneum.
This patient had a perforated gastric ulcer
 VISUALIZATION OF
THE FALCIFORM LIGAMENT
The falciform ligament courses over the free edge of the
liver anteriorly just to the right of the upper lumbar spine.
 Falciform ligament sign.
Free intraperitoneal air may surround the
normally invisible falciform ligament on the
anterior edge of the liver causing that thin,
soft tissue structure to become visible (solid
white arrows) just to the right of the upper
lumbar spine.
SIGNS OF EXTRAPERITONEAL AIR
(RETROPERITONEAL AIR)
The key signs of extraperitoneal (retroperitoneal) air are a streaky,
linear appearance or a mottled, blotchy appearance outlining
extraperitoneal structures and its relatively fixed position, moving
very little or not at all with changes in patient positioning.
 Extraperitoneal air seen on
CT.
Air is seen in the
retroperitoneum (solid black
arrow) on this axial CT scan of
the upper abdomen. Air outlines
the inferior vena cava (solid
white arrow) and the aorta
(dotted white arrow).
SIGNS OF AIR IN THE BOWEL WALL
Air in the bowel wall is called pneumatosis intestinalis
 Pneumatosis seen in profile.
Close-up of the right lower quadrant in an
infant demonstrates a thin curvilinear lucency
that parallels the lumen of the adjacent bowel
(white arrows), an appearance characteristic of
gas in the bowel wall seen in profile. In infants
the most common cause for this finding is
necrotizing enterocolitis
CAUSES AND SIGNIFICANCE OF AIR
IN THE BOWEL WALL
A more common which can occur in the following:
- Chronic obstructive pulmonary disease
- Diseases in which there is necrosis of the bowel wall such as: Necrotizing
enterocolitis in infants and Ischemic bowel disease in adults
- Obstructing lesions of the bowel that raise intraluminal pressure, such
as: Hirschsprung disease in children and Obstructing carcinomas in
adults
 SIGNS OF AIR IN THE BILIARY SYSTEM
Signs of air in the biliary system include tubelike, branching lucencies in the right upper quadrant overlying the liver,
which are central in location and few in number, and gas in the lumen of the gallbladder.
 Air in the biliary tree. Frontal view of the upper abdomen from an upper gastrointestinal
series demonstrates several air-containing tubular structures over the central portion of the
liver consistent with air in the biliary system (white circle). There is also barium in the
gallbladder (white arrow). This patient had a history of a prior sphincterotomy for gallstones
so that reflux of air and barium into the biliary system would be expected.
Causes of pneumobilia include incompetence of the sphincter of Oddi,
prior sphincterotomy,, and gallstone ileus.
The triad of findings in gallstone ileus are air in the biliary system, small
bowel obstruction, and visualization of the gallstone itself.

Gallstone ileus.
The three key findings of gallstone ileus are
present on this study.
Axial CT scan of the upper abdomen shows
air in the lumen of the gallbladder (black
arrow) and dilated small bowel (white
arrow) consistent with a mechanical small
bowel obstruction