Pneumoperitoneum

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1. Anterior Subhepatic Space Free Air

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2. Doges Cap Sign
Gas in Morrison's pouch
may have the following
features

- Triangular in shape
- concave medial border
- positioned inferior to
the right 11th rib

- positioned superior to
the right kidney
3. Air Anterior to Ventral Surface of Liver
• Air sitting against the ventral
surface of the liver can be any
shape and, as in this case, is
frequently "geographical" in
Loading…shape. The liver is a homogenous
organ and should be homogenous
in density on plain film. If the
liver is seen to demonstrate an
uneven density,
pneumoperitoneum should be
considered.

Note also Rigler's sign

4. Rigler’s Sign on supine AXR
• Rigler's sign is named after Leo
G. Rigler.
• The sign refers to the appearance
of the bowel wall on plain film
when it is outlined by
intraluminal and extraluminal air
(arrowed).
• The extraluminal air is free
peritoneal gas.
5. Decubitus Abdomen Sign
• This patient is in the left lateral
decubitus position. It is
conventional in radiography to
mark the side the side that is up.

There is evidence of free air

between the abdominal wall and
the liver (white arrow). There is
also evidence of free fluid in the
peritoneum (black arrow).
6. Falciform Ligament Sign
• The falciform ligament connects
the anterior abdominal wall to
the liver.
• The ligament continues to extend
inferiorly beyond the liver where
it becomes the round ligament
(white arrow).
• Given that the falciform ligament
is situated against the anterior
abdominal wall, it is not
surprising that it becomes
outlined with air in a supine
patient with free abdominal gas.
7. The ‘football’ sign
• The football sign likens the
massively air-filled peritoneum
to an American football.
• This neonatal patient has massive
pneumoperitoneum and could
reasonably be said to display
football sign. There is also
falciform ligament sign, Rigler's
sign and air in the scrotum.
8. Continuous Diaphragm Sign
• There is sufficient air beneath the
diaphragm, the continuous nature
of the diaphragm is
demonstrated.
• Note that the left and right
hemidiaphragms contrasted by
the free gas appear as a
continuous structure.
9. Double Bubble Sign
• The double bubble sign is an
appearance of subdiaphragmatic
gas under the left
hemidiaphragm in which there
Loading… are two collections of
overlapping gas
• subdiaphragmatic free gas
• normal gas on the fundus of the
stomach
• Note that the diaphragm (black
arrow) is a thinner walled
structure than the stomach wall
(white arrow). This distinction is
10. The Cupola Sign
• The Cupola Sign refers to an air
accumulation beneath the central
tendon of the diaphragm (white
arrows)
11. Lesser Sac Gas (saccus minor)
• This image of free gas has
a cupola sign (white arrows) and
a lesser sac gas sign (black
arrows).

• The lesser sac is positioned

posterior to the stomach and is
usually a potential space. There
is free connection between the
lesser sac and the greater sac
through the foramen of Winslow.
12. The Triangle Sign
• The triangle sign refers to small
triangles of free gas that can
typically be positioned between
the large bowel and the
flank(black arrow)
13. Abscess Gas
• This patient has an abscess
(proven on CT). The arrowed
bubbles of gas are suspicious in
that they are not clearly
contained within normal hollow
abdominal viscus. If they were,
for example, contained within
the colon, they would tend to be
aligned in a more linear fashion
and may outline normal haustral
features.
14. Pneumoretroperitoneum
• This patient has free air in the
retroperitoneal space. The air is
seen surrounding the lateral
border of the right kidney (white
arrow). There is other evidence
of free gas including Rigler's
sign.
• If you are not confident that the
appearance is
pneumoretroperitoneum, you can
try an erect and decubitus view
to see if the gas moves. If the gas
is seen to move, it's not in the
Other sign
• The Inverted “V” Sign
• n infants the “inverted V” is
undoubtedly caused by the large
umbilical arteries, in adults I
believe it is the inferior epigastric
vessels that produce the “inverted
V” sign.”
• Urachus Sign
• Air contrasted urachus. Appears as
vertical line between bladder and
umbilicus. Outline of medial
umbilical ligament
• Leaping Dolphins Sign
• Coronary Ligament Outlined by
Air
• the coronary ligament is sited
anterior to the liver
• Air in the Fissure for the
Ligamentum Teres
• Air in the Fissure for the
Ligamentum Teres. May appear in
isolation. Appears as a lucent
vertical stripe over liver
• Pneumo-gall bladder
• Air in the gall bladder fossa
outlining the gall bladder
Urachus sign

• Air contrased urachus

• Vertical line between bladder and
umbilicus

• Outline of medial umbilical

ligament
Inverted V sign
• Supine
• Free air outlineing the lateral
umbilical lig. Coursing inferiorly
and laterally from the umbilicus
• Infant : a. Umbilikalis
• Adult : vasa epigastrics inferior
Leaping dolphins sign
• Air under hemidiafragm and
diapraghmatic muscle slips
visible
Ligamentum teres sign
• Extraluminal air in the fissure for
the lig. Teres
• Linear density running along the
inferior edge of liver