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SIGN OF A

PNEUMOPERITONIUM

REVA ADENAPIO
ADELLA THIANANDA
RAISYA FARAH MONICA
RADHIATUL ADILLAH NST
PNEUMOPERITONEUM

free air within the peritoneal cavity


The most common cause is a perforation of the
abdominal viscus
most commonly, a perforated ulcer
PNEUMOPERITONEUM: THE 14
SIGNS
1-3) RUQ/Liver signs on supine 9) Double Bubble Sign
AXR:
Anterior Subhepatic Space Free Air
Doges Cap Sign
10) Cupola Sign
Air Anterior to Ventral Surface of Liver
11) Lesser Sac Gas
4) Riglers Sign
12) Triangle Sign
5) Decubitus Abdomen Sign

6) Falciform Ligament Sign 13) Abscess Gas

7) Football Sign
14)
Pneumoretroperitoneum
8) Continuous Diaphragm Sign 15) Others
OTHER PATTERNS OF AIR AROUND
LIVER

Doges Cap Sign


1) Anterior Subhepatic Space Free Air

Anterior
subhepatic space
free air tends to
be vaguely linear
in shape

Ind
1. GAS IN SUBHEPATIC SPACE

Supine abdominal radiograph shows an elliptical collection of air within


the subhepatic space
6
1. SIGNS IN PNEUMOPERITONEUM

Erect chest radiograph reveals free gas between the liver and both does
of diaphragm.
7
2. DOGES CAP
SIGN
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

8
2) DOGES CAP SIGN/ MORRISONS
POUCH FREE GAS
Supine; RUQ/Liver sign
2
1. Triangular shaped
2. Sharp lower lateral
corner
3. Concave lateral
border outlining the
medial border of
the liver
4. Positioned inferior
to the 11thrib
Morrisons pouch = 5. Positioned superior
a potential space to the right kidney
between the right
Ind
3) AIR ANTERIOR TO VENTRAL SURFACE
LIVER

Supine; RUQ/ Liver


sign 3
Uneven density in
geographical shape

Ind
4) RIGLERS SIGN
Supine
Bowel wall
outlined by
intraluminal &
extraluminal
air (extraluminal
= free peritoneal
gas)
Both sides of
bowel wall can be
seen
(red arrows)
Ind
4. RIGLERS SIGN

Rigler's sign refers to the appearance of the bowel


wall on plain film when it is outlined by intraluminal
and extraluminal air .The extra luminal air is free
peritoneal gas 12
4. RIGLERS SIGN

Bowel wall visualised on both sides due to intra and extraluminal air
Usually large amounts of free air
May be confused with overlapping loops of bowel, confirm with upright view
5) DECUBITUS ABDOMEN SIGN

Left lateral
decubitus
Air-fluid level
White arrow =
free air between
the abdominal
wall and the
liver
Black arrow =
free fluid in the
peritoneum
Ind
Left lateral decubitus film showing gas between the liver and abdominal
wall.
15
6) FALCIFORM LIGAMENT SIGN

Supine
Falciform ligament
connects the anterior
abdominal wall to the
liver
extends inferiorly
beyond the liver
becomes round
ligament
becomes outlined with
air in a patient with free
abdominal gas

Ind
6. FALCIFORM LIGAMENT SIGN

Normally
invisible.

Supine film, free


air rises over
anterior surface
of liver
6. FALCIFORM LIGAMENT VISUALIZATION

Visualization of Falciform ligament by free gas on either


18
side of the ligament
7) THE FOOTBALL SIGN

massively air-
fi lled peritoneum

Ind
7. FOOTBALL SIGN

Seen with massive


pneumoperitoneum

Most often in children


with necrotising
enterocolitis

In supine position air


collects anterior to
abdominal viscera

Paediatric
Adult
7. FOOT BALL SIGN

>1000 ml air collected abdominal decompression

Here Comes the MASSIVE ones


22
8) CONTINUOUS DIAPHRAGM SIGN

massive
pneumoperitoneum
sufficient air
beneath the
diaphragm
left & right
hemidiaphragms
contrasted by the
free gas appear as a
continuous structure

Ind
9) DOUBLE BUBBLE SIGN

subdiaphragmatic
gas under the left
hemidiaphragm
2 collections of
overlapping gas
subdiaphragmatic free
gas (under black
arrow)
normal gas within the
fundus of the stomach
(under white arrow)

Ind
DOUBLE BUBBLE SIGN

Two collections of overlapping gas- one of these collections is sub


diaphragmatic free gas and the other is normal gas within the fundus of the
stomach 25
10) THE CUPOLA SIGN

Dome-like
Air accumulation
beneath the
central tendon of
the diaphragm

Ind
THE CUPOLA SIGN

An arcuate collection of free intraperitoneal air beneath the central


tendon of diaphragm. The superior border is well defined (arrows)
compared with the inferior extent of the collection. 27
11) LESSER SAC GAS

The lesser sac


positioned posterior
to the stomach
usually a potential
Note:
space
White arrow =
Cupola sign

Ind
LESSER SAC SIGN CUPOLA
SIGN

Lesser Cupola
sac sign
sign (white
(black arrows)
arrows)
The lesser sac is
positioned Air superior
posterior to the to left lobe of
stomach and is liver
usually a
potential space.
There is free
connection
between the
lesser sac and
the greater sac
through
foramen
the
of Double Bubble Sign
Winslow
12) THE TRIANGLE SIGN

menggambark
an daerah
segitiga udara
diantara 2
lingkaran usus
dengan
dinding
abdomen
13) ABSCESS GAS

arrowed bubbles of
gas NOT clearly
contained within
normal hollow
abdominal viscus
NOT aligned in a
linear fashion nor
outline normal
haustral features
Ind
14) PNEUMORETROPERITONEUM

Th i s p a t i e nt h a s f re e a i r
in th e re t rop e r i t on e a l
space. The air is seen
s u rro un d i n g t he l a te ra l
b ord e r of the ri g ht
k i dn e y (white a rrow ) .
Th e re is ot h e r e v i d e n c e
of f re e g a s i n c l u d i ng
R i g l e r' s s i g n .

I f y ou a re n o t c on fi de n t
t h a t t he a pp e a ra n c e i s
p n e u m ore t rop e ri t on e u m ,
y ou c a n t ry a n e re c t a n d
d e c u b i t us vi e w t o s e e i f
t h e g a s m ov e s . I f th e
g a s i s s e e n t o m ov e , i t 's
n ot in the
re t rop e ri t on e um .
14) PNEUMORETROPERITONEUM

Air seen surrounding


the lateral border of
the kidney
(retroperitoneal
organs)
If the gas is seen to
move in an erect
and decubitus view,
it's NOT in the
retroperitoneum

Ind
TRY TO GUESS ???

Foot ball sign


Falciform
ligaments sign

Riglers Sign

Foot Ball sign


OTHER SIGN
PNEUMOPERITONIUM
CONDITIONS SIMULATING
PNEUMOPERITONEUM

Chilaiditis
syndrome-
intestine
between liver
and diaphragm

36
CRESCENT SIGN II
Free air under the diaphragm

Best demonstrated on
upright chest x rays or
left lateral decubitus

Easier to see under


right diaphragm
OTHERS: URACHUS SIGN

Air contrasted
urachus
Vertical line
between bladder
and umbilicus
Outline of medial
umbilical
ligament

Ind
Urachus Sign

udara tampak melapisi


urachus. Urachus
tampak seperti garis
tipis linier di tengah
bagian bawah
abdomen yang
berjalan dari kubah
vesika urinaria ke arah
kepala. Dasar urachus
tampak sedikit lebih
tebal daripada apeks.
OTHERS: THE INVERTED V SIGN

Supine
Free air outlining the
lateral umbilical
ligaments, coursing
inferiorly and
laterally from the
umbilicus
Infants: umbilical
arteries
Adults: inferior
epigastric vessels
http://dx.doi.org/10.1148/radiology.151.1.
Ind
6230689
OTHERS: LEAPING DOLPHINS SIGN

Air under
hemidiaphragm
and
diaphragmatic
muscle slips
visible

Ind
OTHERS: LIGAMENTUM TERES SIGN

Extraluminal air in
the fi ssure for the
Ligamentum Teres
Linear density
running along the
inferior edge of
the falciform
ligament

Picture: DOI: Emerg Med J 2011;28:728


doi:10.1136/emj.2010.098699Ind
10.1056/NEJMicm0904627
PNEUMATOSIS INTESTINALIS

Intramural air,
best appreciated
in profi le
AIR IN THE BILIARY TREE
One or two tube-like branching lucencies in the RUQ,
conform to location of major bile ducts
DIFFERENTIAL DIAGNOSIS

Chilaiditis syndrome (interposition


hepatodiapragmatica, subphrenic displacement of
the colon, pseudopneumoperitoneum)

Basal Lung Atelectasis (colapsed alveoli linear


form, pneumonia, COPD, TBC )

Subphrenic abcess (acute pancreatitis,


peritonitis)
Peritonitis
CHIL AIDITIS SIGN

May mimic air under


the diaphragm
Look for haustral
folds
Get left lat decub to
confi rm

In patients who have


cirrhosis or flattened
diaphragms due to lung
hyperinflation, a void is
created within the upper
abdomen above the liver.
This space may be filled by
bowel. If this bowel is air
filled then it may mimic
free gas.
CONDITIONS SIMULATING
PNEUMOPERITONEUM

Right sided subphrenic


abscess

47
CONDITIONS SIMULATING PNEUMOPERITONEUM

Large bulla at the base of the


right lung mimics a large
pneumoperitoneum

48
REFERENCES

Soto JA, Luce y BC. (2 00 9). Eme rg enc y Rad iology: The Re quisites .
Pg 3 05 .
Khan AN . (2 01 4). Pneumope riton eum Imaging. M e dscape .
Fulle r M J. (2 01 1, May 27). Pne umop e riton e um. WikiRad iogr aph y.
We bs ite: h ttp:/ /www.w ikiradiogr aphy.com/ pag e/ Pn e umope ritone um
Me nu ck L, Sie mer s PI. (1 976 ). Pne umope r iton eu m: Impor tance of
R ight U p pe r Quadrant Fe atu re s. Am J Roe ntge no. 1 27 :75 3-75 6.
We ine r CI, Diacon is JN , De nn is JM. (1 973 , April). The In ve rte d V:
A N ew S ign of Pne umope r iton eu m. R S NA. Vol. 1 07, Issue 1.
Bray JF. (19 84 , April). Th e inve rte d V sig n of
pne u mope ritone um. R SNA. Vol. 1 51 , Iss ue 1 : 45-4 6.
Le e CH. (20 10, Ju ne 24 ). Radiologic Signs of Pn eu mope ritone um.
N En gl J Me d 20 10 ; 3 62: 24 10.
Image s in e me rge ncy me dic ine . Emer g M e d J 20 11 ;28 :72 8
doi: 10 .1 13 6/e mj.20 10.09 86 99
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