Signs of Pneumoperitoneum on Plain Film
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This document discusses various radiographic signs that can indicate the presence of free air or pneumoperitoneum within the peritoneal cavity. It begins by explaining that pneumoperitoneum is most commonly caused by a perforation of the abdominal viscus, usually the stomach or bowel. It then presents 15 different named radiographic signs visible on abdominal x-rays that suggest pneumoperitoneum, such as the anterior subhepatic space free air sign and Rigler's sign. Each sign is accompanied by an illustrative image and brief explanation. Additional less common signs are also listed. References for further information are provided.
Signs of Pneumoperitoneum on Plain Film
- 2. “ within the peritoneal cavity” The most common cause is a perforation of the abdominal viscus – most commonly, a Soto JA, Lucey BC. (2009). Emergency Radiology: The Requisites. Pg 305 Khan AN. (2014). Pneumoperitoneum Imaging. Medscape.
- 3. 1-3) RUQ/Liver signs on supine AXR: • Anterior Subhepatic Space Free Air • Doges Cap Sign • Air Anterior to Ventral Surface of Liver 4) Rigler’s Sign 5) Decubitus Abdomen Sign 6) Falciform Ligament Sign 7) Football Sign 8) Continuous Diaphragm Sign 9) Double Bubble Sign 10) Cupola Sign 11) Lesser Sac Gas 12) Triangle Sign 13) Abscess Gas 14) Pneumoretroperitoneum 15) Others
- 4. • Supine; RUQ/Liver sign 1 • Linear shape Index
- 5. • Supine; RUQ/Liver sign 2 shaped lateral corner border outlining the medial border of the liver 4. Positioned inferior to the 11thrib 5. Positioned superior to the right kidney Morrison’s pouch = a potential space between the right kidney & the liver Index
- 6. • Supine; RUQ/ Liver sign 3 • Uneven density in Index
- 7. • Supine • Bowel wall (extraluminal = free peritoneal gas) of bowel wall can be seen (red arrows) Index
- 8. • Left lateral decubitus • Air-fluid level between the abdominal wall and the liver in the peritoneum Index
- 9. • Supine • Falciform ligament – connects the anterior abdominal wall to the liver – extends inferiorly beyond the liver → becomes round ligament – becomes in a patient with free abdominal gas Index
- 11. • massive pneumoperitoneum → sufficient air beneath the diaphragm • left & right hemidiaphragms contrasted by the free gas appear as a Index
- 12. • subdiaphragmatic gas under the left hemidiaphragm – subdiaphragmatic free gas (under black arrow) – normal gas within the fundus of the stomach (under white arrow) Index
- 13. • Air accumulation beneath the central tendon of the diaphragm Index
- 14. • The lesser sac – positioned posterior to the stomach – usually a potential space Note: White arrow = Cupola sign Index
- 15. • small triangles of free gas positioned between the large bowel and the flank Index
- 16. • arrowed NOT clearly contained within normal hollow abdominal viscus – NOT aligned in a linear fashion nor outline normal haustral features Index
- 17. • 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 in the retroperitoneum Index
- 18. Urachus Sign Inverted V Sign Leaping Dolphins Sign Ligamentum Teres Sign Index
- 19. • Air contrasted urachus • Vertical line between bladder and umbilicus • Outline of medial umbilical ligament Index
- 20. • Supine • Free air outlining the , coursing inferiorly and laterally from the umbilicus – Infants: umbilical arteries – Adults: inferior epigastric vessels http://dx.doi.org/10.1148/radiology.151.1.6230689 Index
- 21. • Air under hemidiaphragm and diaphragmatic muscle slips visible Index
- 22. • Extraluminal air in the fissure for the Ligamentum Teres • Linear density running along the inferior edge of the falciform ligament Emerg Med J 2011;28:728 doi:10.1136/emj.2010.098699 Picture: DOI: 10.1056/NEJMicm0904627 Index
- 23. More Signs: • Coronary Ligament Outlined by Air – The coronary ligament sited anterior to the liver • Pneumo-gall bladder – Air in the gall bladder fossa outlining the gall bladder Index
- 24. • 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