Pneumoperitoneum

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.

Why is Pneumoperitoneum Important?

Pneumoperitoneum is most often caused by perforated abdominal viscus and can present an acute
medical emergency.
The Radiological signs of pneumoperitoneum are among the most important signs in radiology, indeed in
Medicine. Sometimes the amount of free gas is small and you may have to work to demonstrate it (i.e. modify
the film technique). Miss it and the patient may die Abdominal X-rays made easy. 2nd edition, James D. Begg
Churchill Livingstone, Elsevier, 2006
p94

Plain Film Signs of Pneumoperitoneum

Radiographers are more likely to demonstrate pathologies that they are familiar with. As
James Begg stated, sometimes you have to 'work to demonstrate pneumoperitoneum'. What
he meant by this is that the supine signs of pneumoperitoneum may be subtle- the
radiographer must be able to identify the signs on the supine image and know what
supplementary views will prove the existence of free intraperitoneal gas.

RUQ/liver signs on supine AXR

There are 3 separate signs of free air around the liver as follows.

Pneumoperitoneum: Importance of Right Upper Quadrant Features

LESLIE MENUCK AND PAUL I. SIEMERS
Am J Roentgeno! 127:753-756. 1976

1.

Anterior Subhepatic Space Free Air (RUQ sign 1)

Pneumoperitoneum: Importance of Right Upper Quadrant

Features
LESLIE MENUCK AND PAUL I. SIEMERS
Am J Roentgeno! 127:753-756. 1976

Anterior subhepatic space free air tends to be

vaguely linear in shape (arrowed). A visible
medial border of the liver is often seen outlined by
fat. A careful examination of this image (left)
shows the arrowed density to be air density rather
than fat density.
The differentiation between fat and air density
becomes easier with experience. This image of
normal fat surrounding the liver shows a
consistent density continuous with the
properitoneal fat stripe.

2.

Doges Cap Sign (RUQ sign 2)

Doges Cap sign refers to free air in

Morrison's pouch. Morrison's pouch is
normally a potential space between the right
kidney and the liver. This is a particularly
difficult sign of pneumoperitoneum for
several reasons. Firstly, it may be the only
sign of pneumoperitoneum and may be very
subtle. Secondly, it can be easily
misinterpreted as gas in the duodenum.
Gas in Morrison's pouch may have the
following features

Triangular in shape
concave medial border
positioned inferior to the right 11th
rib

positioned superior to the right

kidney

Pneumoperitoneum: Importance of Right Upper Quadrant Features

LESLIE MENUCK AND PAUL I. SIEMERS
Am J Roentgeno! 127:753-756. 1976

This sign is known as Doges Cap

sign. The Italian Doges wore this
distinctively shaped cap. Gas in Morrison's
pouch is only loosely shaped like a Doges
cap and should not be taken too literally.
Bear in mind that the "triangle Sign" was
already taken!

Morrisons pouch free gas demonstrated on

supine Radiographs typically show the following
Characteristics
1.Typically triangular shaped
2.The lower lateral corner is commonly sharp
3.The lateral border is typically concave and
outlines the medial border of the liver
4.It is positioned inferior to the 11thrib
5.It is positioned superior to the right kidney

3. Air Anterior to Ventral Surface of Liver(RUQ sign 3)

Air sitting against the ventral surface of the liver can be
any shape and, as in this case, is frequently
"geographical" in shape. The liver is a homogenous
organ and should be homogenous in density on plain
film. If the liver is seen to demonstrate an uneven
density, pneumoperitoneum should be considered.
Note also Rigler's sign

4. Decubitus Abdomen Sign

This patient is in the left lateral decubitus
position. It is conventional in radiography to
mark the side the side that is up.
There is evidence of free air between the
abdominal wall and the liver (white arrow).
There is also evidence of free fluid in the
peritoneum (black arrow).

5. Riglers Sign on supine AXR

Rigler's sign is named after Leo G. Rigler. The sign
refers to the appearance of the bowel wall on plain
film when it is outlined by intraluminal and
extraluminal air (arrowed). The extraluminal air is
free peritoneal gas.

6. Falciform Ligament Sign

The falciform ligament connects the anterior
abdominal wall to the liver. The ligament continues
to extend inferiorly beyond the liver where it
becomes the round ligament (white arrow). Given
that the falciform ligament is situated against the
anterior abdominal wall, it is not surprising that it
becomes outlined with air in a supine patient with
free abdominal gas.
This is an axial CT scan image of a patient with
pneumoperitoneum. The free gas is seen outlining
the anterior abdominal wall and several loops of
bowel. The arrowed structure is the falciform
ligament surrounded by free intraperitoneal gas.
The falciform ligament sign is almost never seen in
isolation. If there is enough free air to outline the
falciform ligament, there is usually enough air to
also provide at least a Rigler's sign. In this
case(left), there is a Rigler's sign as well as RUQ
signs. Note also bilateral nephrostomy tubes insitu.

7. The football sign

The football sign likens the massively airfilled peritoneum to an American football. To
extend the simile a little further, the
falciform ligament has been likened to the
seam in the football, and the rarely seen
medial and lateral umbilical ligaments are
likened to the football laces.
This neonatal patient has massive
pneumoperitoneum and could reasonably be
said to display football sign. There is also
falciform ligament sign, Rigler's sign and air
in the scrotum.

http://shop.sportsmanswarehouse.com.au/images/product_images/1660/fo
ot001.jpg

John W. Rampton, MD
The Football Sign
(Radiology 2004;231:81-82.)
RSNA, 2004

8. Continuous Diaphragm Sign

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

9. Double Bubble Sign

The double bubble sign is an appearance
of subdiaphragmatic gas under the left
hemidiaphragm in which there are two
collections of overlapping gas- one of
these collections is subdiaphragmatic free
gas and the other is normal gas within the
fundus of the stomach. Note that the
diaphragm (black arrow) is a thinner
walled structure than the stomach wall
(white arrow). This distinction is
sometimes useful in distinguishing
between the two structures.
Note also free subdiaphragmatic gas
under the right hemidiaphragm

10. The Cupola Sign.

The Cupola Sign refers to an air

accumulation beneath the central tendon
of the diaphragm (white arrows)
The term cupola comes from a dome
such as this famous dome of the Duomo

in Florence.

11. Lesser Sac Gas

This image of free gas has a cupola
sign (white arrows) and a lesser sac gas sign
(black arrows). The lesser sac is positioned
posterior to the stomach and is usually a
potential space. There is free connection
between the lesser sac and the greater sac
through the foramen of Winslow.

12. The Triangle Sign

The triangle sign refers to small triangles of free gas
that can typically be positioned between the large
bowel and the flank(black arrow)

12. Abscess Gas

This patient has an abscess (proven on CT).

The arrowed bubbles of gas are suspicious in
that they are not clearly contained within
normal hollow abdominal viscus. If they
were, for example, contained within the
colon, they would tend to be aligned in a
more linear fashion and may outline normal
haustral features.

13. 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.
An axial CT scan image is shown with air

around the right kidney (black arrow).

There are a number of other signs of pneumoperitoneum that are less commonly seen. These
signs are sufficiently rare to not warrant close examination. Equally, for reasons of
completeness, they have been included on this page.
14. Leaping Dolphins Sign
Air under hemidiaphragm and diaphragmatic
muscle slips visible

15. Urachus Sign

Air contrasted urachus. Appears as vertical line between

bladder and umbilicus. Outline of medial umbilical
ligamen

16. The Inverted V Sign

" in infants the inverted V is undoubtedly caused by
the large umbilical arteries, in adults I believe it is the
inferior epigastric vessels that produce the inverted
V sign.

17. Air in the Fissure for the Ligamentum Teres

Air in the Fissure for the Ligamentum Teres. May
appear in isolation. Appears as a lucent vertical
stripe over liver

More signs:

18. Coronary Ligament Outlined by Air

19. Pneumo-gall bladder : Air in the gall bladder fossa outlining the gall bladder

References

Soto JA, Lucey BC. (2009). Emergency Radiology: The Requisites. Pg 305.
Khan AN. (2014). Pneumoperitoneum Imaging. Medscape.
Fuller MJ. (2011, May 27). Pneumoperitoneum. WikiRadiography. Website:
http://www.wikiradiography.com/page/Pneumoperitoneum
Menuck L, Siemers PI. (1976). Pneumoperitoneum: Importance of Right Upper Quadrant
Features. Am J Roentgeno. 127:753-756.
Weiner CI, Diaconis JN, Dennis JM. (1973, April). The Inverted V: A New Sign of
Pneumoperitoneum. RSNA. Vol. 107, Issue 1.
Bray JF. (1984, April). The inverted V sign of pneumoperitoneum. RSNA. Vol. 151, Issue
1: 45-46.
Lee CH. (2010, June 24). Radiologic Signs of Pneumoperitoneum. N Engl J Med 2010;
362:2410.
Images in emergency medicine. Emerg Med J 2011;28:728 doi:10.1136/emj.2010.098699