Pneumoperitoneum:

14 Signs on Plain Film

Ext.

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.

Pneumoperitoneum: The 14 Signs

1-3) RUQ/Liver signs on supine AXR:

1) Anterior Subhepatic Space Free Air

Supine; RUQ/Liver
sign 1
Linear shape
ed
r
a
p
l
a
m
o
m
C
or
n
with ensity
d
t
a
f

Ind

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
5. Positioned superior
to the right kidney
Morrisons pouch =
a potential space
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

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

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

7) The Football Sign

massively air-filled
peritoneum

Ind

8) Continuous Diaphragm Sign

massive
pneumoperitoneu
m 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

10) The Cupola Sign

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

Ind

11) Lesser Sac Gas

The lesser sac

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

Ind

12) The Triangle Sign

small triangles of
free gas positioned
between the large
bowel and the
flank

Ind

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
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

Other Signs of Pneumoperitoneum

Inverted Dolphins
Urachus
Leaping
Ligamentum
V Sign Sign

Ind

Others: Urachus Sign

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

Ind

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 fissure for the
Ligamentum Teres
Linear density
running along the
inferior edge of the
falciform ligament

Picture: DOI:
10.1056/NEJMicm0904627

Emerg Med J 2011;28:728

doi:10.1136/emj.2010.098699
Ind

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

Ind

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

Thank You