Signs of Pneumoperitoneum on Plain Film

14 signs of pneumoperitoneum on plain film

1. Pneumoperitoneum : 14 Signs on Plain Film Ext. จริยา ภรณ์ พัฒ นกุลเลิศ

2. Pneumoperitoneum “ free air within the peritoneal cavity” The most common cause is a perforation of the abdominal viscus most commonly, a perforated ulcer Soto JA, Lucey BC. (2009). Emergency Radiology: The Requisites. Pg 305 Khan AN. (2014). Pneumoperitoneum Imaging. Medscape .

3. Pneumoperitoneum : The 14 Signs

4. 1) Anterior Subhepatic Space Free Air Supine; RUQ/Liver sign 1 Linear shape Compared with normal fat density Index

5. 2 ) Doges Cap Sign/ Morrison’s Pouch Free Gas Supine; RUQ/Liver sign 2 T riangular shaped Sharp lower lateral corner Concave lateral border outlining the medial border of the liver P ositioned inferior to the 11thrib P ositioned superior to the right kidney Morrison’s pouch = a potential space between the right kidney & the liver Index

6. 3) Air Anterior to Ventral Surface Liver Supine; RUQ/ Liver sign 3 Uneven density in geographical shape Index

7. 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) Index

8. 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 Index

9. 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 Index

10. 7) The Football Sign massively air-filled peritoneum Index

11. 8 ) Continuous Diaphragm Sign massive pneumoperitoneum → sufficient air beneath the diaphragm left & right hemidiaphragms contrasted by the free gas appear as a continuous structure Index

12. 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) Index

13. 10) The Cupola Sign Dome-like Air accumulation beneath the central tendon of the diaphragm Index

14. 11) Lesser Sac Gas The lesser sac positioned posterior to the stomach usually a potential space Note: White arrow = Cupola sign Index

15. 12) The Triangle Sign small triangles of free gas positioned between the large bowel and the flank Index

16. 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 Index

17. 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 Index

18. Other Signs of Pneumoperitoneum Index

19. Others: Urachus Sign Air contrasted urachus V ertical line between bladder and umbilicus Outline of medial umbilical ligament Index

20. 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 Index

21. Others: Leaping Dolphins Sign Air under hemidiaphragm and diaphragmatic muscle slips visible Index

22. 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 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. 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

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