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Radiography Pneumoperitoneum Pneumoperitoneum Cases The Abdominal Plain FilmTerminology Small Bowel Obstruction Neonatal Lines, Tubes and Catheters Trauma Obliques of the Cervical Spine Nutcracker Fracture of the
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Pneumoperitoneum
Introduction
Pneumoperitoneum refers to the presence of free gas within the peritoneal cavity. The plain films signs of pneumoperitoneum are both diverse and sometimes difficult to identify. This page provides an overview of the plain film diagnosis of pneumoperitoneum.
The plain film signs of pneumoperitoneum are well established in the literature as follows 1 Anterior Subhepatic Space Air 2 3 4 5 6 7 8 9 10 11 12
Doges Cap Sign (free Air in Morrison's Pouch) Air Anterior to Ventral Surface of Liver
Riglers sign on supine AXR (also known as double-wall or bas-relief sign) Falciform Ligament Sign The football sign The cupola. Air accumulation beneath the central tendon of the diaphragm Continuous diaphragm sign The triangle- air trapped between three loops of bowel Air under diaphragm on erect cxr Air outlined against liver/flank on decub AXR Otherdiaphragmatic muscle slips, ligamentum teres air, Double Gastric Fundus sign, The Inverted-V sign, Scrotal air Abscess Gas Pneumoretroperitoneum
13 14
(RUQ sign 1)
Anterior subhepatic space free air tends to be vaguely linear in shape (arrowed). A visible medial border of the liver is often seen outlined by fat. A careful examination of this image (left) shows the arrowed density to be air density rather than fat density. The differentiation between fat and air density becomes easier with experience. This image of normal fat surrounding the liver shows a
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http://bp3.blogger.com/_iAsK5lmVXqM/Rpn6Q091zNI/AAAAAAAAAQE/qDaIjgpsZa4/s320/doge.jpg
Morrisons pouch free gas demonstrated on supine Radiographs typically show the following Characteristics
1.Typically triangular shaped 2.The lower lateral corner is commonly sharp 3.The lateral border is typically concave and outlines the medial border of the liver 4.It is positioned inferior to the 11thrib 5.It is positioned superior to the right kidney
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The falciform ligament sign is almost never seen in isolation. If there is enough free air to outline the falciform ligament, there is usually enough air to also provide at least a Rigler's sign. In this case(left), there is a Rigler's sign as well as RUQ signs. Note also bilateral nephrostomy tubes insitu.
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http://shop.sportsmanswarehouse.com.au/images/product_images/1660/foot001.jpg John W. Rampton, MD The Football Sign (Radiology 2004;231:81-82.) RSNA, 2004
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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.
Notes
Air under hemidiaphragm and diaphragmatic muscle slips visible
Reference
http://www.thaigastro.com/book/file/Thai-Journal-ofgastroenterology-vol-6-no-3-627306.pdf
Air contrasted urachus. Appears as vertical line between bladder and umbilicus. google Outline of medial umbilical ligament
" in 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.
The Inverted V Sign of Pneumoperitoneum John F. Bray, M.B., Ch.B., F.R.C.S. (Ed.), F.R.C.R.2 Radiology 1984; 151: 45-46 Radiology; 1991. 178: 489 - 492 http://myweb.lsbu.ac.uk/dirt/museum/margaret/752-7121000221.jpg google
Air in the Fissure for the Ligamentum Teres. May appear in isolation. Appears as a lucent vertical stripe over liver
Coronary Ligament Outlined by Air The coronary ligament is sited anterior to the liver. Pneumo-gall bladder Air in the gall bladder fossa outlining the gall bladder
14. Pneumoretroperitoneum
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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 retroperitoneum. An axial CT scan image is shown with air around the right kidney (black arrow).
Case 1
This in-patient was referred for chest radiography following open mitral valve surgery. There appears to be free air under the right hemidiaphragm. This was interpreted as 'colonic interposition' (Chilaiditis sign) but I suspect that it is a 'leaping dolphins sign'. The appearance of septa within the air collection under the right hemidiaphragm is probably outlining the costal muscle slips of the hemidiaphragm rather than representing outline of bowel wall. There also appears to be a negative 'silhouette sign' of the liver (black arrow). There is an azygous lobe (white arrow). There is a pleural effusion on the left.
Quoted from Morton A. Meyers Dynamic radiology of the abdomen: normal and pathologic anatomy
The lateral chest image similarly demonstrates a negative 'silhouette sign' involving the liver (black arrow). There appears to be a triangle of pleural fluid at the base of an inferior accessory fissure. There are three metallic rings associated with the mitral valve surgery. There is loss of visualisation of the left hemidiaphragm associated with a left pleural effusion.
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Case 2
This 78 year old man presented to the Emergency Department with a history of abdominal pain. He was examined and referred for an acute abdominal and chest X-ray examination. There appears to be gas under the right hemidiaphragm. Note that there is bowel gas superimposed over the liver suggesting colonic interpositiona known cause of false pneumoperitoneum. If this appearance represented pneumoperitoneum, you would expect to see air-contrasted liver.
The lateral chest projection image demonstrates the appearance again of air under the right hemidiaphragm. The is an associated air-fluid level. This appearance is more likely to indicate colonic interposition than pneumoperitoneum. Where there is a clinical question of pneumoperitoneum, a decubitius abdominal plain film would be helpful.
It is useful to be able to distinguish between the appearance of This paient has a pneumothorax. The right hemidiaphragm air under the right hemi-diaphragm, colonic interposition and contrasted with air in the pleural space resembles the liver pneumothorax. contrasted with free air in the peritoneum(left)
This appearance of colonic interposition does bear some similarity to the appearance of pneumoperitoneum (above left).
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The black arrow identifies the aircontrasted liver. The aircontrasted costal muscle slip is marked with a white arrow
The white arrowed structure is probably a haustral marking and the black arrowed structure is diaphragmatic
Case 3
This is a 60 year old lady with known Crohn's disease and abdominal pain. She was referred for an abdominal plain film. The large bowel wall is visible along both flanks. The liver is also outlined by fat.
There is fat interposed between the inferior border of the liver and the hepatic flexure of the colon (white arrow) There is properitoneal fat contrasting the caecum (black arrow) These appearances are not associated with pneumoperitoneum. The scattered air densities over the liver probably represent air within bowel.
Case 4
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This is a supine bedside chest X-ray image post intubation. At a cursary glance there may appear to be air under the right hemidiaphragm
This is in fact air above the diaphragm rather than under it. This patient has a right sided pneumothorax with a deep sulcus sign. The pneumothorax is also visible at the right lung apex (arrowed)
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Discussion
Pneumoperitoneum is an important plain film finding. Untreated, pneumoperitoneum has poor morbidity and mortality outcomes. Radiographers who are familiar with the plain film appearances of pneumoperitoneum, particularly the supine appearances, are more likely to undertake supplementary views to concusively demonstrate the pathology. Moreover, they will also have the opportunity to report the finding immediately to the referring doctor.
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Latest page update: made by M.J.Fuller , May 27 2011, 1:45 PM EDT (about this update - complete history) Keyword tags: abdominal viscera abscess bas relief Chilaiditis sign continuous diaphragm cuplosa sign cupola sign doges cap double bubble falciform ligament football sign foramen of winslow free gas greater sac juxtaphrenic peak lesser sac morrison's pouch perforated peritoneum pneumoperitoneum radiography rigler's sign triangle sign More Info: links to this page M.J.Fuller
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