Introduction
Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity.
The plain films signs of pneumoperitoneum are both diverse and sometimes
difficult to identify. This page provides an overview of the plain film diagnosis of
pneumoperitoneum.
The plain film signs of pneumoperitoneum are well established in the literature as
follows
1
10
11
12
13
Abscess Gas
14
Pneumoretroperitoneum
(RUQ sign 1)
(RUQ sign 2)
Triangular in shape
concave medial border
positioned inferior to the right 11th rib
positioned superior to the right kidney
http://bp3.blogger.com/_iAsK5lmVXqM/Rpn6Q091zNI/AAAAAAAAAQE/
qDaIjgpsZa4/s320/doge.jpg
sign 3)
http://shop.sportsmanswarehouse.com.au/images/product_images/16
60/foot001.jpg
John W. Rampton, MD
The Football Sign
(Radiology 2004;231:81-82.)RSNA, 2004
Another
manifestation of
massive
pneumoperitoneum
is the continuous
diaphragm sign.
Where there is
sufficient air
beneath the
diaphragm, the
continuous nature
of the diaphragm
is demonstrated.
Note that the left
and right
hemidiaphragms
contrasted by the
free gas appear as
a continuous
structure.
image source unknown
Notes
Reference
Leaping
Dolphins
Sign
Air under
hemidiaphragm and
diaphragmatic muscle
slips visible
Urachus
Sign
The
Inverted
V Sign
Air in the
Fissure for
the
Ligamentum
Teres
http://www.thaigastro.com/book/file/Thai-Journalof-gastroenterology-vol-6-no-3-627306.pdf
Coronary
The coronary ligament
Ligament
is sited anterior to the
Outlined by
liver.
Air
http://myweb.lsbu.ac.uk/dirt/museum/margaret/752712-1000221.jpg
bladder
14. Pneumoretroperitoneum
This patient has free air in
the retroperitoneal space. The
air is seen surrounding the
lateral border of the right
kidney (white arrow). There is
other evidence of free gas
including Rigler's sign.
If you are not confident that
the appearance is
pneumoretroperitoneum, you
can try an erect and decubitus
view to see if the gas moves.
If the gas is seen to move, it's
not in the retroperitoneum.
Case 1
This in-patient was referred
for chest radiography following
open mitral valve surgery.
There appears to be free air
under the right hemidiaphragm.
This was interpreted as
'colonic interposition'
(Chilaiditis sign) but I suspect
that it is a 'leaping dolphins
sign'. The appearance of septa
within the air collection under
the right hemidiaphragm is
probably outlining the costal
muscle slips of the
hemidiaphragm rather than
representing outline of bowel
wall.
There also appears to be a
negative 'silhouette sign' of
the liver (black arrow).
There is an azygous lobe (white
arrow).
There is a pleural effusion on
the left.
Quoted from
Morton A. Meyers
Dynamic radiology of the abdomen: normal and
pathologic anatomy
Case 2
This 78 year old man presented
to the Emergency Department
with a history of abdominal
pain. He was examined and
referred for an acute
abdominal and chest X-ray
examination.
The PA chest projection image
shows some prominent
interstitial markings. There
appears to be gas under the
right hemidiaphragm. Note
that there is bowel gas
superimposed over the liver
suggesting colonic
interposition- a known cause of
false pneumoperitoneum. If
this appearance represented
pneumoperitoneum, you would
expect to see air-contrasted
liver.
Discussion
Pneumoperitoneum
Pneumothorax
It is useful to be able to
distinguish between the
appearance of air under
This paient has a
the right hemi-diaphragm,
pneumothorax. The right
colonic interposition and
hemidiaphragm contrasted
pneumothorax.
with air in the pleural
space resembles the liver
The black arrow identifies
contrasted with free air in
the aircontrasted liver.
the peritoneum(left)
The aircontrasted costal
muscle slip is marked with
a white arrow
Colonic Interposition
Case 3
Case 4
This is a supine bedside chest X-ray image post intubation. At a cursary glance
there may appear to be air under the right hemidiaphragm
This is in fact air above the diaphragm rather than under it. This patient has a
right sided pneumothorax with a deep sulcus sign. The pneumothorax is also visible
at the right lung apex (arrowed)
Discussion
Pneumoperitoneum is an important plain film finding. Untreated, pneumoperitoneum
has poor morbidity and mortality outcomes. Radiographers who are familiar with
the plain film appearances of pneumoperitoneum, particularly the supine
appearances, are more likely to undertake supplementary views to concusively
demonstrate the pathology. Moreover, they will also have the opportunity to report
the finding immediately to the referring doctor.