Signs in pneumoperitoneum

Pneuperitoneum is best discovered on Abdominal Radiograph.
These signs help in easy detection of the condition

1. Please visit www.jssmcradiology.com for more radiology education Signs in Pneumoperitoneum :

2. 1) Anterior Subhepatic Space Free Air Supine; RUQ/Liver sign 1 Linear shape Compared with normal fat density Please visit www.jssmcradiology.com for more radiology education

3. 2) Doges Cap Sign/ Morrison’s Pouch Free Gas Supine; RUQ/Liver sign 2 Triangular shaped Sharp lower lateral corner Concave lateral border outlining the medial border of the liver Positioned inferior to the 11thrib Positioned superior to the right kidney Morrison’s pouch = a potential space between the right kidney & the liver Please visit www.jssmcradiology.com for more radiology education

4. 3) Air Anterior to Ventral Surface Liver Supine; RUQ/ Liver sign 3 Uneven density in geographical shape Please visit www.jssmcradiology.com for more radiology education

5. 4) Rigler’s Sign Supine Bowel wall outlined by intraluminal & extraluminal air ( extraluminal = free peritoneal gas) Both sides of bowel wall can be seen (red arrows) Please visit www.jssmcradiology.com for more radiology education

6. 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 Please visit www.jssmcradiology.com for more radiology education

7. 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 Please visit www.jssmcradiology.com for more radiology education

8. 7) The Football Sign massively air-filled peritoneum Please visit www.jssmcradiology.com for more radiology education

9. 8) Continuous Diaphragm Sign massive pneumoperitoneum → sufficient air beneath the diaphragm left & right hemidiaphragms contrasted by the free gas appear as a continuous structure Please visit www.jssmcradiology.com for more radiology education

10. 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) Please visit www.jssmcradiology.com for more radiology education

11. 10) The Cupola Sign Dome-like Air accumulation beneath the central tendon of the diaphragm Please visit www.jssmcradiology.com for more radiology education

12. 11) Lesser Sac Gas The lesser sac positioned posterior to the stomach usually a potential space Note: White arrow = Cupola sign Please visit www.jssmcradiology.com for more radiology education

13. 12) The Triangle Sign small triangles of free gas positioned between the large bowel and the flank Please visit www.jssmcradiology.com for more radiology education

14. 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 Please visit www.jssmcradiology.com for more radiology education

15. 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 Please visit www.jssmcradiology.com for more radiology education

16. Other Signs of Pneumoperitoneum Please visit www.jssmcradiology.com for more radiology education

17. Others: Urachus Sign Air contrasted urachus Vertical line between bladder and umbilicus Outline of medial umbilical ligament Please visit www.jssmcradiology.com for more radiology education

18. 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.151.1.6230689 Please visit www.jssmcradiology.com for more radiology education

19. Others: Leaping Dolphins Sign Air under hemidiaphragm and diaphragmatic muscle slips visible Please visit www.jssmcradiology.com for more radiology education

20. Others: Ligamentum Teres Sign 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 Please visit www.jssmcradiology.com for more radiology education

21. 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 Please visit www.jssmcradiology.com for more radiology education

22. Please visit www.jssmcradiology.com for more radiology education. You can contribute for the collection by email to [email protected]