Pneumoperitonium

The term pneumoperitoneum refers to the presence of air within the peritoneal cavity. The
most common cause is a perforation of the abdominal viscusmost commonly, a perforated
ulcer, although a pneumoperitoneum may occur as a result of perforation of any part of the
bowel; other causes include a benign ulcer, a tumor, or trauma. The exception is a perforated
appendix, which seldom causes a pneumoperitoneum.
The presence of a pneumoperitoneum does not, however, always imply a perforation, because
a number of other (mostly nonsurgical) conditions are associated with pneumoperitoneum.
Likewise, not every bowel perforation results in a pneumoperitoneum; some perforations seal
over, allowing little gas to escape. A pneumoperitoneum is common after abdominal surgery;
it usually resolves 3-6 days after surgery, although it may persist for as long as 24 days after
surgery.
The peritoneum is a thin, serous membrane that lines the abdominal cavity. It has parietal and
visceral layers, the latter being reflected over the abdominal viscera. A thin layer of serous
fluid, which acts as a lubricant, separates the 2 layers. Several intra-abdominal organs are
invaginated by visceral peritoneum to such an extent that they are almost completely covered
by peritoneum; they have double layers of peritoneum within them as mesenteries and
ligaments (see the images below).

Pneumoperitoneum. Diagram of transverse section of the

abdomen shows peritoneal reflection.

Pneumoperitoneum.
Diagram of a sagittal section of the female abdomen and pelvis shows peritoneal reflection.

Pneumoperitoneum. Diagrams of the right upper quadrant

show the location of the oblong collection of air in the right subhepatic space seen on a plain

supine abdominal radiograph.

Pneumoperitoneum. Diagram of
the right upper quadrant shows a triangle-shaped collection of air in the Morison pouch, as
seen on a plain supine abdominal radiograph. This collection is usually bound by the 11th rib,
and it may be triangular (doge's cap), crescent shaped, or semicircular.

Pneumoperitoneum. Diagram of the right upper quadrant

shows the location of a circular collection of air projected over the liver interposed between
the anterior liver surface and the anterior thoracic and abdominal wall seen on a plain supine
abdominal radiograph.
The most common cause of a spontaneous pneumoperitoneum is the introduction of air
through the female genital tract (see the images below).

Pneumoperitoneum. Upright chest radiograph shows a large

pneumoperitoneum outlining the spleen and the superior surface of the liver.

Pneumoperitoneum. (Left) Sagittal sonogram through the liver

shows a comet-shaped artifact due to free air in the anterior subphrenic space, which causes
shadowing. Also note the free peritoneal fluid. (Right) A transverse oblique sonogram
through the midabdomen shows dilated loops of small bowel with a streak of free fluid

between the bowel loops.

Pneumoperitoneum. Contrastenhanced axial CT scan through the liver shows a collection of air anterior to the liver. Also
note the air surrounding the gallbladder and the leakage of water-soluble contrast material
from a perforated duodenal ulcer.

Preferred examination
CT is regarded as the criterion standard for the detection of a pneumoperitoneum; it provides
exquisite scans, and it is theoretically more sensitive than plain abdominal radiography.
However, CT is not always required when a pneumoperitoneum is suspected. Despite the
contrary consensus, the accuracy of supine abdominal radiography closely approximates CT
when the entire abdomen is imaged.
US is usually the first investigation performed in emergent patients. US is a noninvasive test
that is widely available and is particularly valuable in children, pregnant women, and
individuals of reproductive age. Some studies have reported sensitivities greater than that of
plain abdominal radiography in the diagnosis of a pneumoperitoneum.[1, 2] Compared with
plain radiography, US examination also has the advantage of depicting other changes, such as
free abdominal fluid and inflammatory masses.[3, 4, 5]

Limitations of techniques
Free intraperitoneal air is often missed with plain radiology. The failure to detect free air is
more a function of lacking standardization and of inadequate technique. In most institutions,
a kidney, ureter, bladder (KUB) image is used instead of other images in cases of suspected
pneumoperitoneum. These radiographs are insufficient for the diagnosis of a
pneumoperitoneum because the uppermost portion of the peritoneal cavity, which reveals
important signs, may be excluded from the examination.
If proper technique is applied, contrast-enhanced studies and CT scanning can be avoided.
Although a CT scan is considered a criterion standard in the diagnosis of a
pneumoperitoneum, it is expensive in terms of both radiation burden and cost.
With both conventional radiology and CT, oral contrast material is used to opacify the lumen
of the GI tract and to demonstrate a bowel leak. The leak may be too small, or it may have

sealed, and extravasation of the contrast material may not occur. When a distal small or large
bowel perforation is suspected, one major limitation of the use of oral contrast material is that
several hours may be required to opacify the bowel. Thus, the randomness of bowel
opacification, the difficulty encountered in securing the cooperation of a sick patient, and the
relative clinical urgency for diagnosis limit the value of oral contrast enhancement.
In addition, oral contrast material may obscure relevant clinical information, such as the
presence of an appendicolith and bowel hemorrhage, although these may not be relevant in
terms of bowel perforation. Although US is a noninvasive and relatively inexpensive test, it
remains operator dependent, and it has limitations in patients who are obese and in those with
a large amount of intra-abdominal gas.[6, 7]
Abnormal abdominal gas collections are classified according to the anatomic location, which
is often the key to the differential diagnosis.

Extraluminal gas
Extraluminal gas may be involved in pneumoperitoneum or gas within an abscess or fistulous
tract. Gas within a pelvic abscess usually indicates that the abscess is of GI origin. Gas within
an abscess of pelvic inflammatory disease (PID) is unusual. Gas within the paracolic gutter is
usually associated with GI perforation. Diverticulitis may produce extraluminal gas trapped
within the adjacent mesentery.

Intraluminal gas
Intraluminal gas may be normal or abnormal. The gas may be intratumoral (within a
neoplasm in association with infection or bowel communication), intramural, within a
paralyzed loop of bowel, within an obstructed Meckel diverticulum (secondary infection), or
within the biliary tree. Normal intraluminal gas can be differentiated by the presence of gas
within the bowel lumen in association with peristalsis that is visible on fluoroscopy or
ultrasonography (US).

Intraparenchymal gas
Within the portal vein, intraparenchymal gas may sometimes be seen on real-time US as gas
microbubbles moving through the liver or as linear collections of hyperlucent branching gas
at the periphery of the liver. Gas may be seen in a liver abscess. The differential diagnosis
between liver microabscesses and microcalcification may be difficult to make with US. In
most other organs, intraparenchymal gas usually indicates an abscess.

Intratumoral gas
Intratumoral gas typically occurs in a gastric leiomyoma or leiomyosarcoma; in such cases,
the gas may be seen extending from the lumen of the stomach into the tumor. Intratumoral
gas may also be seen in hepatic tumors after chemoembolization; in such cases,
differentiation of the gas from an abscess may be difficult with the use of images alone.

Intramural gas

Intramural gas may be related to ischemia. US features that are distinctive of infection
include high-amplitude echoes that do not change with the patient's position or with
peristalsis. Adjacent bowel wall thickening is often present. Crohn disease and
cytomegalovirus (CMV) infection are less common causes of intramural bowel gas.
Pneumatosis coli is often better shown with CT than with US. Acute emphysematous
cholecystitis, which often occurs in diabetic patients and the elderly, shows evidence of
intramural gas on US. Confusion may occur with mural calcification, which is often
curvilinear but which does not have the characteristic ring-down artifact associated with air
bubbles. Adenomyosis of the gallbladder may cause a comet-tail artifact.
The presence of free intra-abdominal gas usually indicates a perforated abdominal viscus.
The most common cause is perforation of a peptic ulcer. Patients with such conditions need
urgent surgery. Occasionally, patients with vague abdominal symptoms have unequivocal
features of a pneumoperitoneum, but there is little clinical evidence of peritonism. These
patients have a pneumoperitoneum without peritonitis. They are treated expectantly and do
not require surgery.

Male versus female anatomy

In males, the peritoneal cavity is completely closed, but in females, the peritoneal cavity
communicates with the genital tract via the fallopian tubes, which provide a potential
pathway for suction of air into the peritoneal cavity. The fallopian tubes also constitute a
possible pathway of infection from the genital tract.

Peritoneal reflections and ligaments

Various peritoneal reflections and ligaments interrupt the peritoneal cavity.
At the level of the umbilicus, the obliterated fetal urachus (median umbilical cord) forms a
shallow ridge that extends cephalad from the dome of the urinary bladder to the umbilicus.
The median umbilical cords, which represent the obliterated umbilical arteries, extend from
the internal iliac arteries to the umbilicus in the shape of an inverted V.
The falciform ligament is a double layer of peritoneum that forms anteriorly near the midline
between the umbilicus and the esophagus. It passes backward and splits to enclose the liver.
Superiorly, peritoneal layers form the triangular and coronary ligaments, which enclose the
bare area of the liver. The layers of peritoneum investing the liver unite on its visceral surface
to form the lesser omentum, which passes from the liver to the esophagus, the stomach, and
the first part of the duodenum. The free edge of the lesser omentum between the porta hepatis
and duodenum contains the portal vein; the hepatic artery and common bile duct lie
anteromedially and anterolaterally, respectively.
The layers of the lesser omentum split to enclose the stomach and then reunite to form the
greater omentum and gastrosplenic and lienorenal ligaments. In the free edge of the falciform
ligament lies the ligamentum teres (the obliterated fetal left umbilical vein), which passes into
the groove between the quadrate lobe and the left lobe of the liver.
The transverse colon is enclosed by the transverse mesocolon, which is attached posteriorly
to the anterior aspect of the pancreas.

The lesser sac lies behind the lesser omentum and the stomach. The spleen, which is attached
by the gastrosplenic and lienorenal ligaments, forms the left wall of the lesser sac. The right
of the sac communicates with the main peritoneal cavity via the foramen of Winslow.
These reflections and peritoneal spaces are important radiologically because it is here that air
accumulates in a pneumoperitoneum.

Special concerns
Most pregnant women (90%) experience significant improvement or complete resolution of
peptic ulcer disease. Complications of peptic ulcer disease such as hemorrhage and
perforation are rare in pregnancy. Radiology has a role in the evaluation of suspected
perforation, but the use of conventional radiography involves irradiation of the fetus. With
lateral chest radiography, the fetus is excluded from the direct beam. US is readily available
in most centers and can be used in the pregnant patient.
In a series of 100 patients, Woodring and Heiser found that use of upright lateral chest
radiographs led to a confirmation of pneumoperitoneum in 98% of patients[8] ; by contrast, use
of standard upright posteroanterior (PA) radiographs resulted in a confirmation in only 80%
of patients, suggesting that upright lateral views are more sensitive than standard upright PA
chest radiographs.
Negative findings support conservative management. For cases in which there is strong
clinical suspicion but the radiographic findings are negative, the decision to use further
imaging such as CT or to perform surgical exploration must be made on an individual basis.
Although a negative lateral chest radiograph excludes a pneumoperitoneum in most cases, the
physician should not hesitate to perform a full abdominal series when the index of clinical
suspicion is high; in such instances, the benefit outweighs the disadvantage of the small
radiation dose to the fetus.
Pneumoperitoneum has a variety of causes, including pneumatosis intestinalis. Pneumatosis
intestinalis may be associated with benign causes or may occur in patients with intraabdominal cancer. Lee and associates retrospectively and blindly reviewed 84 patients with
pneumatosis intestinalis to determine the overall proportion of clinically worrisome and
benign pneumatosis intestinalis occurring in patients with cancer and to evaluate associated
risk factors on CT. The study revealed that benign pneumatosis intestinalis was more
prevalent than clinically worrisome pneumatosis intestinalis. The study also revealed that CT
features of mesenteric stranding, bowel thickening, bowel dilation, portomesenteric venous
gas and ascites, and localization confined to the small bowel were worrisome signs. The
location and pattern, such as linear, cystic, or both, were also important.[9]
Optimal radiographic technique is important with a suspected abdominal perforation. At least
2 radiographs should be obtained, including a supine abdominal radiograph and either an
erect chest image or a left lateral decubitus image. The patient should remain in position for
5-10 minutes before a horizontal-beam radiograph is acquired. A lateral chest x-ray has been
found to be even more sensitive for the diagnosis of pneumoperitoneum than an erect chest xray. The images below depict radiographic technique.

Pneumoperitoneum. Plain radiograph of the right upper quadrant shows a

tiny streak of air under the diaphragm due to a pneumoperitoneum.

Pneumoperitoneum. Upright chest radiograph shows a large

collection of air under both hemidiaphragms due to perforated duodenal ulcer.

Pneumoperitoneum. Upright chest radiograph shows a large

pneumoperitoneum outlining the spleen and the superior surface of the liver.

Pneumoperitoneum. Images in a 24-year-old man known to

have Crohn disease who presented with acute abdominal pain. (Left) Supine radiograph of
the right upper quadrant shows a vague lucency overlying the liver. (Right) Lateral decubitus
radiograph shows an obvious pneumoperitoneum. Note also the air-fluid levels within the
bowel due to associated ileus. At surgery, a perforated terminal ileum secondary to Crohn

disease was diagnosed.

Pneumoperitoneum. This elderly
patient was knocked down by a car in a motor vehicle accident. Her main complaint was hip
pain. Plain abdominal radiograph of the pelvis confirms the presence of a fracture of the neck
of the left femur, but also note a bowel relief sign (arrow). At surgery, a perforation of the

small bowel secondary to blunt abdominal trauma was confirmed.

Pneumoperitoneum. Coned view of the lower abdomen shows the lateral umbilicus sign
(arrow), which is a sign of a large pneumoperitoneum on a plain abdominal radiograph. Note

also the bowel relief sign.

Pneumoperitoneum. Coned view of the
lower abdomen shows the urachus sign (arrows), which is another sign of a large

pneumoperitoneum on a plain abdominal radiograph.

Pneumoperitoneum. Diagrams of the right upper quadrant show the location of the oblong
collection of air in the right subhepatic space seen on a plain supine abdominal radiograph.

Pneumoperitoneum. Supine abdominal radiograph shows an

elliptical collection of air within the subhepatic space. Note also the bowel relief sign.

Pneumoperitoneum. Diagram of the right upper quadrant

shows a triangle-shaped collection of air in the Morison pouch, as seen on a plain supine
abdominal radiograph. This collection is usually bound by the 11th rib, and it may be

triangular (doge's cap), crescent shaped, or semicircular.

Pneumoperitoneum. Plain abdominal radiograph of a patient with a pneumoperitoneum
shows a triangular collection of air in the Morison pouch (solid arrows). Also note the bowel

relief sign (open arrows).

Pneumoperitoneum. (Left) Supine
chest radiograph shows a tiny collection of air under the diaphragm (arrow) in a patient with
pneumoperitoneum. (Right) Supine abdominal radiograph shows a triangular collection of air

in the Morison pouch (arrow).

Pneumoperitoneum. Diagram

of the right upper quadrant shows the location of a circular collection of air projected over the
liver interposed between the anterior liver surface and the anterior thoracic and abdominal

wall seen on a plain supine abdominal radiograph.

Pneumoperitoneum. A 66-year-old man was admitted to the hospital with urinary retention
and was being examined for prostatic pathology. While he was in the ward, he had a sudden
onset of acute abdominal pain. Findings on this supine radiograph were interpreted as being
normal, but note the pear-shaped lucency projected over the liver indicative of a

pneumoperitoneum.
Pneumoperitoneum. A 49-year-old man
was admitted to the hospital with acute abdominal pain. Findings from the initial plain
abdominal radiographs were interpreted as being normal. Because the cause of his abdominal
pain was not clear, an upper GI series performed with water-soluble contrast material was
requested. (Left) Radiograph obtained early in the study shows no leakage, but note the
triangular collection of air within the Morison pouch. (Right) When this earlier plain
radiograph was interpreted, the collection of air within the Morison pouch was seen; this had

escaped detection earlier (arrow).

Pneumoperitoneum. Supine
abdominal radiograph in a 26-year-old man with known Crohn disease who presented with
acute abdominal pain. Findings on the initial plain radiographs were interpreted as normal.
Radiograph shows barium within the stomach, but note air within the lesser sac and in the
Morison pouch. At surgery, a perforated duodenal ulcer was confirmed.

Pneumoperitoneum. Supine abdominal radiograph shows a falciform

ligament (arrow).
Pneumoperitoneum. (Left) Upper GI barium
series in a patient who presented with acute abdominal pain. Note the duodenal ulcer crater
and air within the ligamentum teres (arrow). (Right) Follow-up barium study shows that the

barium leak and air within the ligamentum teres (arrow) persists.
Pneumoperitoneum. Plain abdominal radiograph in a 24-year-old man who presented with
acute abdominal pain 24 hours after undergoing an upper GI series with barium. Radiography
was performed to evaluate peptic ulcer disease. Note that barium has been released into the
anterior subphrenic space (arrows). Note also the delineation of the falciform ligament of the
escaped barium. Also seen is barium within the grooves of mesenteric vessels (arrows). The

bowel relief sign is obvious.

Pneumoperitoneum. Left,
Posteroanterior (PA) chest radiograph in a patient receiving long-term steroid therapy who
presented with breathlessness but no abdominal symptoms. A large pneumoperitoneum is
present, and because of the lack of abdominal signs, she was observed. (Right) Two weeks
later, a repeat anteroposterior (AP) chest radiograph was obtained because the patient felt
vaguely unwell, although she had no abdominal signs. Note the air-fluid level to the left of
the upper lumbar spine and left basal pleural effusion. At surgery, a retroperitoneal abscess
secondary to a colonic perforation was diagnosed. Patients who are diabetic or those taking

steroids are prone to silent perforations.

Pneumoperitoneum. This
patient was unwell after endoscopic retrograde cholangiopancreatography (ERCP). Plain
abdominal radiograph shows a falciform ligament (arrow) and the bowel relief sign. The
patient was treated conservatively because of a lack of abdominal signs. He recovered fully.

Pneumoperitoneum. Plain abdominal radiograph in a patient in

whom a retropneumoperitoneum developed after endoscopic retrograde

cholangiopancreatography (ERCP).
Pneumoretroperitoneum.
Chest radiograph (left) and plain radiograph (right) show surgical emphysema and

retroperitoneal air secondary to a retroperitoneal bowel perforation.

Pneumoperitoneum. Image shows bowel perforation after bowel infarction. Note the large

pneumoperitoneum and air within the portal venous radicals.

Pneumoperitoneum, mimics. Pneumatosis coli secondary to necrotizing enterocolitis.

Pneumoperitoneum, mimics. Plate atelectasis at the right lung

base mimics a small pneumoperitoneum.

Pneumoperitoneum,
mimics. Large bulla at the base of the right lung mimics a large pneumoperitoneum.

Pneumoperitoneum, mimics. Image shows colonic interposition.

Note the haustra.

Pneumoperitoneum, mimics. Air-containing

bowel loops within a Morgagni hernia.

Pneumoperitoneum, mimics.
Air within the portal venous radicals secondary to bowel infarction is an ominous sign in

adult patients.
the biliary tree after papillotomy.

Pneumoperitoneum, mimics. Image shows air within

Some authors suggest a complete free-air series, which includes the acquisition of a left
lateral decubitus image after the patient is in the proper position for 20 minutes and the
acquisition of an upright radiograph after 5 minutes and a supine radiograph after 1 minute.
The total examination time is therefore 26 minutes, which becomes cumbersome for patients
who are ill and in pain.
The plain radiographic signs of a pneumoperitoneum have been classified into those of a
small pneumoperitoneum and those of a large pneumoperitoneum associated with more than
1000 mL of free air.[10, 11, 12, 13]

Signs of a large pneumoperitoneum

Signs of a large pneumoperitoneum include the following:

The football sign, which usually represents a large collection of air within the greater
sac. The air seems to outline the entire abdominal cavity. Some authorities apply the

term football sign to the air surrounding the falciform ligament, which looks like the
laces of a football.

The gas-relief sign, the Rigler sign, and the double-wall sign are all terms applied to
the visualization of the outer wall of bowel loops caused by gas outside the bowel
loop and normal intraluminal gas.[14] Free intraperitoneal gas and intraperitoneal fluid
in excess of 1000 mL are usually required to elicit this sign.

The urachus is a vestigial peritoneal reflection not normally seen on a plain abdominal
radiograph. It has the same opacity as other soft tissue intra-abdominal structures, but
when a pneumoperitoneum occurs, air outlines the urachus. The urachus is then seen
as a thin midline linear structure in the lower abdomen proceeding cephalad from the
dome of the urinary bladder. The base of the urachus may be slightly thicker than the
apex.

The lateral umbilical ligaments, which contain the inferior epigastric vessels, may
become visible as an inverted V sign in the pelvis as a result of a large
pneumoperitoneum.

A telltale triangle sign represents a triangular pocket of air between 2 loops of bowel
and the abdominal wall.

Scrotal air may be seen in children as a result of peritoneal intrascrotal extension

(through patent process vaginalis).

Free air under the diaphragm may depict the diaphragmatic muscle slips as arcuate
soft tissue bands, arching parallel to the diaphragmatic dome.

Gas within the lesser sac may be present, particularly with a perforation of the
posterior wall of the stomach.

Air may be present around the spleen.

Signs of partial large bowel obstruction with a sigmoid diverticulum perforation may
occur in association with signs of a pneumoperitoneum.

On a left lateral decubitus radiograph, free air is apparent around the inferior edge of
the liver, which forms the least dependent part of the abdomen in that position. In
obese patients, particularly women, the least dependent part may be overlying the
hips, a point at which free air may be present.

Right upper quadrant gas

In a series of 250 patients with proven hollow organ perforation, Chui et al found that most of
the signs of free air on supine radiographs were localized in the right upper quadrant. The
most common sign was the anterior superior oval sign (described below).[15]

A round, oval, or pear-shaped collection of air may be projected over the liver shadow
between the ventral liver surface and the anterior thoracic or abdominal wall (anterior
superior oval sign). This collection may be solitary or present in several smaller locules. The
liver shadow normally has no gas overlying it, though such gas does occur in association with
the following conditions: colonic interposition, subphrenic abscess, liver abscess with gasforming organisms, the presence of portal venous gas, the presence of biliary gas, and as an
effect of chemoembolization.
Menuck et al published an important report in 1976 describing the importance of right upper
quadrant gas, which is best seen in a small pneumoperitoneum on supine radiographs.[16]
An oblong saucer-shaped or cigar-shaped collection of air may be present in the subhepatic
space inferior to the lower edge of the liver.
A triangular collection of air may be seen in the Morrison pouch, which is bound by the left
11th rib. The configuration of this air collection varies and may be semicircular, crescent
shaped, or triangular. This has been likened to a doge's cap.
Parahepatic gas bubbles may be seen lateral to the right edge of the liver.
The cupola sign (saddlebag or moustache sign) represents gas trapped under the central
tendon of the diaphragm.
Small collections of air around the periduodenal area normally occur with a retroperitoneal
perforation in the second part of the duodenum, but it has also been described with a
pneumoperitoneum.
The falciform ligament is a linear soft tissue opacity coursing vertically between the
umbilicus and the ligamentum teres notch in the inferior surface of the liver. The falciform
ligament may be thin and of uniform diameter, but it is occasionally a linear lobulated
structure that may be several millimeters thick.
Gas within the ligamentum teres notch may be seen as an inverted Vshaped collection on the
undersurface of the liver at the junction of the right and left lobes.
Gas within the ligamentum teres is seen as a vertical slitlike or oval lucency lying between
the 11th and 12th right ribs and 2.5-4 cm lateral to the spinal edge. The gas collection may be
2-7 mm wide and 6-20 mm long.
Air in the gallbladder fossa is a recently described sign that is better demonstrated with CT
than with radiography.

Use of contrast medium in the evaluation of suspected perforation

Not infrequently, patients with an acute abdomen and suspected perforation have no free gas,
as assessed on plain radiographs. The differential diagnosis usually includes acute
cholecystitis, pancreatitis, and a perforated ulcer.
To aid in the examination, about 50 mL of water-soluble contrast agent is given orally or via a
nasogastric tube with the patient lying right-side down. Fluoroscopy may be used to examine

the patient; spot images are obtained after the patient stays in the right lateral decubitus
position.
In patients with a perforated ulcer, contrast material may leak into the peritoneum.
Fluoroscopy is not always essential, and plain abdominal radiography may be performed.
Patients with pancreatitis may also be examined with this technique; in these patients, an
edematous, stretched duodenal loop may be visualized. The use of ionic water-soluble
contrast medium should be avoided because patients may inadvertently inhale it.

Degree of confidence
Plain radiography remains the mainstay in imaging an acute abdomen, including a perforated
abdominal viscus. As little as 1 mL of free gas can be detected on a plain radiographeither
an erect chest image or a left lateral decubitus abdominal image.[17] Pneumoperitoneum is
detectable in 56% of patients by using a supine abdominal image. In approximately one half
of patients with a pneumoperitoneum, gas overlies the right upper quadrant.

False positives/negatives
Mimics of a pneumoperitoneum include the following:

Colonic interposition between the superior surface of the liver and the diaphragm

(Chilaiditi syndrome) (see the following image)

Pneumoperitoneum, mimics. Image shows colonic interposition. Note the haustra.

Undulating diaphragm

Basal atelectasis situated above and parallel to the diaphragm, which is bandlike and
has a normally aerated lung above and below (see the following image)

Pneumoperitoneum, mimics. Plate atelectasis at the

right lung base mimics a small pneumoperitoneum.

Basal lung bulla (see the image below)

Pneumoperitoneum, mimics. Large bulla at the base of the right lung mimics a large
pneumoperitoneum.

Subphrenic abscess caused by gas-forming organisms

Pyonephrosis caused by gas-forming organisms

Supradiaphragmatic curvilinear pulmonary collapse

Cysts of pneumatosis coli (see the following image)

Pneumoperitoneum, mimics. Pneumatosis coli secondary to necrotizing enterocolitis.

Subphrenic fat has a curvilinear lucency, which is usually in a more lateral position

Pneumoretroperitoneum

Mimics of ligamentum teres fissure gas include the following:

Air in the biliary tree

Pneumoperitoneum, mimics. Image
shows air within the biliary tree after papillotomy.

Air in the portal venous system

Pneumoperitoneum, mimics.
Air within the portal venous radicals secondary to bowel infarction is an ominous sign
in adult patients.

Fat in the fissure of ligamentum teres

CT can readily depict a pneumoperitoneum, as in the images below. Animal

experiments have revealed that CT can depict as little as 5 cm of cubic free air in the
peritoneum. In a supine position, anteriorly placed gas can generally be differentiated
from gas within the bowel. With any perforation, an outpouring of inflammatory fluid
of varying quantities can be observed within the peritoneum; the amount depends on
the site of perforation. This fluid is again readily detected with CT. The cause of the
perforation can sometimes be diagnosed. Such perforations may be associated with a
carcinoma, diverticulitis, or appendicitis.[18, 19, 20, 21, 22, 23, 24]

Pneumoperitoneum. Contrast-enhanced axial CT scan

through the liver shows a collection of air anterior to the liver. Also note the air
surrounding the gallbladder and the leakage of water-soluble contrast material from a

perforated duodenal ulcer.

Pneumoperitoneum.
Nonenhanced axial CT through the tip of the liver shows leakage of oral contrast

material (arrows) from a perforated gastric ulcer.

Pneumoperitoneum: Posterior perforation of a duodenal ulcer showing inflammatory
fluid around the gallbladder mimicking acute cholecystitis.

Degree of confidence

CT is regarded as a criterion standard in the assessment of a pneumoperitoneum.

CT is useful in identifying even a small amount of extraluminal gas, particularly when
plain radiographic findings are nonspecific. CT is less dependent on the patient's
position and the technique used.

False positives/negatives

CT does not always help in differentiating between pneumoperitoneum of benign

cause and pneumoperitoneum caused by a condition that requires urgent surgery. The
anteriorly located gas from a pneumoperitoneum is sometimes difficult to differentiate
from gas in a distended bowel. In addition, with CT, it is difficult to localize the site
of the perforation.
The presence of free gas in the peritoneum is nonspecific. It may be the result of
bowel perforation, recent surgery, or peritoneal dialysis.