Abdominal X-ray

Although the erect chest X-ray is a much more sensitive investigation for pneumoperitoneum,
there are several signs that may be useful in detecting free gas on an abdominal X-ray.

Rigler's/double wall sign

Rigler's sign (also known as the double wall sign) is the appearance of lucency (gas) on both
sides of the bowel wall.

Rigler's/double wall sign - diagram

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Rigler's/double wall sign - diagram

Normally only the inner wall of the bowel is visible

If there is pneumoperitoneum both sides of the bowel wall may be visible

Rigler's/double wall sign - example

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Rigler's/double wall sign - example

The double wall sign (Rigler's sign) is visible

Gas separates bowel segments and forms sharp angles and triangles (asterisks)

Football sign - example

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Football sign - example

2 radiographs were required to completely cover the abdomen in this large patient
A large volume of free gas has risen to the front of the peritoneal cavity resulting in a
large round black area - 'football sign'
The double wall sign (Rigler's) is also visible (arrowhead)
Liver edge - example (close up)

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Liver edge - example (close up)

Gas may be seen outlining soft tissues structures such as the falciform ligament, or the
liver edge