Abdominal Radiology

https://doi.org/10.1007/s00261-019-02331-6

REVIEW

Pathognomonic imaging signs in abdominal radiology

Christopher Kloth1 · Daniel Vogele1 · Horst Brunner1 · Meinrad Beer1 · Stefan Andreas Schmidt1

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
The imaging evaluation of the abdomen is of crucial importance for every radiologist. In addition to ultrasound, conventional
radiographs and contrast-enhanced computed tomography (CT) are the most common imaging procedures in the abdominal
region. Numerous pathognomonic signs should be known in this context by every radiologist. Radiographs of the abdomen
are an often used first step in radiologic imaging, while CT examinations are carried out for further differentiation, in onco-
logical settings and in time-critical emergency situations. A fast and clear assignment of these signs to a specific disease
is the basis for a correct diagnosis. This pictorial review describes the most common pathognomonic signs in abdominal
imaging. The knowledge of these pictograms is therefore essential for radiologists interested in abdominal medicine and
should also be addressed in training and further education.

Keywords  Diagnostic imaging · Abdominal radiography · Computed tomography · Magnetic resonance imaging ·
Professional education

Introduction Abdominal gas formations

The imaging evaluation of the abdomen is of crucial impor- Cupola sign

tance for every radiologist. In addition to ultrasound, con-
ventional radiographs and contrast-enhanced computed
tomography (CT) are the most common imaging procedures
in the abdominal region. Radiographic images of the abdo-
men are an often used first step in radiologic imaging, while
CT examinations are carried out for further differentia-
tion, in oncological settings and in time-critical emergency
situations. In all radiologic modalities, there are numerous
pathognomonic signs which should be known by the radiolo-
gist. A fast and clear assignment of these signs to a specific
disease is the basis for a correct diagnosis. This pictorial
review describes the most common pathognomonic signs
in abdominal imaging.
Free intraperitoneal air within the median subphrenic space
is described as the “cupola sign” [1, 2]. Typically, the sign is
visible on radiographs at the thoraco-abdominal region when
the patient was examined in supine position (Fig. 1). The air
cupola projects onto the median, central diaphragm parts
overlaying with the lower thoracic spine. Because of the
sharp, defined, dome-like boarders between the air and the
epigastric tissues, it has its name from the cupola. Intraperi-
toneal air accumulates particularly under the diaphragm, but
also beneath the central tendon of the diaphragm and within
the median subphrenic space [1, 2]. This space is defined by
the ventral stomach and the gastrohepatic ligament [1]. Due
to the manifold potential life-threatening causes of pneu-
moperitoneum, the sign is important to know. Computed
tomography is essential for further differentiation regarding
the underlying reason.

Coffee bean sign

* Christopher Kloth
christopher.kloth@uniklinik‑ulm.de The coffee bean sign (Fig. 2) is a pathognomonic radio-
1
Department of Diagnostic and Interventional Radiology,
graphic sign of dilated bowel that resembles the fissure of a
Ulm University Medical Center, Albert‑Einstein‑Allee 23, coffee bean [3, 4]. The reasons can be a sigmoid volvulus or
89081 Ulm, Germany

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Vol.:(0123456789)
 Abdominal Radiology

Fig. 1  Cupola Sign. Radiograph of thoracic-abdominal transition of cupola sign. Besides the pneumoperitoneum in the median sub-
a 62-year-old male patient 3  days after surgery of the bladder with phrenic space, free air is also demarked directly under the diaphragm
demarked air in the median subphrenic space (arrows), known as on the right and on the left side (asterix)

Fig. 2  Coffee bean sign. Abdominal radiograph examination (a) and enhanced CT images each in coronal view in soft tissue (b) and lung (c)
window with dilated bowel reminiscent of the fissure of a coffee bean

a large bowel obstruction. Volvulus represents an abdominal

emergency and is one of the most common causes of large
bowel obstruction in adults [5]. It is typically seen in elderly
men over 50 years of age [5]. A potential colonoscopic
detorsion is the treatment of choice for stable patients with-
out ischemia. The coffee bean sign can be seen as a pathog-
nomonic sign on radiographs, which is diagnostic in 57–90%
of patients [5]. Additional contrast-enhanced abdominal CTs
are often performed due to unspecific clinical symptoms or
to exclude ischemia or perforation.

Rigler and pseudo Rigler sign

Rigler sign

The Rigler sign was described first by the American radi-

ologist Leo George Rigler in 1941 [6, 7]. It is defined by
the visibility of the bowel wall and serosal surface on both
sides through free air in the abdominal cavity (pneumoperi-
toneum, Fig. 3). Because of this it is also called the double
wall sign [8]. The sign shows the presence of free air along Fig. 3  Rigler sign. Abdominal radiograph examination of a 2-week-
old male child with demarked bowel wall in the middle upper abdo-
the luminal bowel wall on supine abdominal radiographs
men. The examination was 1 week after volvulus operation, a perito-
and reflects always an emergency situation because an intes- neal tube line is still in the lower abdomen. The Rigler sign (arrows)
tinal perforation must be excluded [9]. Early diagnosis of demarked the free air around the bowel wall beside the feeding tube
intestinal perforation or other potential threatening reasons in the upper abdomen

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Abdominal Radiology

(infection, trauma, and medication) is obligatory. It can be

also caused by surgical manipulation or diagnostic interven-
tions so that a precise anamnesis is necessary.
Sensitivity for the detection of pneumoperitoneum by
abdominal radiography varies in the literature between 60
and 90% depending on the amount of free air. CT scan has
greater sensitivity and specificity than conventional radio-
graphic technique [10].

Pseudo Rigler sign

In addition to the Rigler sign, a similar popular and wide-

spread sign is the Pseudo Rigler sign (Fig.  4) which is
defined by a lack of visualization of both sides of the intes-
tinal wall when two dilated bowel loops have contact during
X-ray [11]. Various diagnoses or pathomechanisms are pos-
sible for this imaging sign: In addition to free fluid between
the contacting bowel walls, an inflammatory wall thickening
is also conceivable. Fig. 5  Football Sign. Radiograph in supine position of a 3-day-old
male premature infant showing massive pneumoperitoneum caused
by perforation of the stomach (arrows). Free abdominal gas leads to
Abdominal gas formations in pediatrics the football sign showing an oval radiolucency and the median umbil-
ical ligament and the falciform ligament as the sutures reminiscent of
Football sign an American football

After spontaneous or iatrogenic perforation of a hollow
viscus with massive pneumoperitoneum, the football sign
can be seen on supine abdominal radiographs commonly in
infants [12]. In these cases, the abdominal cavity is outlined
by gas as an oval radiolucency, and the median umbilical
ligament and the falciform ligament are representing the
sutures of an American football (Fig. 5). The football sign
was first described in 1960 by Miller et al. [13]. It is often
seen in children with advanced necrotizing enterocolitis, and
bowel obstruction with secondary perforation or iatrogenic
perforation [14].
Double bubble sign
Duodenal atresia is a rare congenital disease and can be seen
in 1 in 5000 to 10,000 live births [15]. If duodenal atresia is
not diagnosed prenatally, the diagnosis can be made radio-
graphically with plain abdominal radiographs after birth.

Fig. 4  Pseudo Rigler Sign. Abdominal radiograph examination a in
supine position of a 62-year-old male patient with myelodysplastic
syndrome after allogeneic stem cell transplantation. After an epi-
sode of diarrhea, the patient had bloated abdomen and reduced bowel
movement. Due to suspected ileus and differential diagnosis of a
graft-vs-host disease of the intestine, an additional contrast-enhanced
computed tomography was performed after the radiograph examina-
tion (b, c). In coronal and axial series, free fluid is identified (arrows),
analog to the abdominal x-ray. Typical Pseudo Rigler sign can be
seen here, which is defined by a lack of visualization of both sides of
the intestinal wall when two dilated bowel loops have contact during
X-ray

13

Typically, the Double bubble sign (Fig. 6) is presenting as
a large air-filled stomach in the left upper abdomen and a
smaller, more distal bubble to the right of midline which rep-
resents a dilated proximal duodenum [16]. Duodenal atresia
is often associated with other anomalies, including trisomy
21 and cardiac malformations [17]. The obstruction is usu-
ally located distal to the ampulla of Vater, commonly caused
by an error of duodenal re-canalization during the eighth
to the tenth week of embryological development. Neonates
Fig. 6  Double bubble sign. Abdominal radiograph examination in
supine position of a 4-day-old female infant with a duodenal atresia
showing two air-filled bubbles representing the stomach and the duo-
denum (arrows). Additionally, a feeding tube and an umbilical venous
catheter is shown
Fig. 7  Coral reef aorta. Unenhanced transversal CT images of a 60-year-old female patient are presented in soft tissue (a) and lung (b) window.
Multiplanar reconstructions with sagittal view on the aorta in bone (c) and lung window (d) are given
13
Abdominal Radiology
with duodenal atresia are presenting with vomiting typically
following the first oral feeding. Treatment involves nasogas-
tric suction to decompress the stomach followed by surgery
to correct the obstruction [18].
Imaging signs in sectional imaging (CT/MRI)
Vascular signs
Coral reef aorta
Extensive squamous calcifications of the aortic lumen with
ulcerations and an almost occlusive stenosis of the vessel
lumen due to the regular width of aortic diameter is the phe-
nomenon of a coral reef aorta (Fig. 7). The phenomenon
was named in 1984 by Qvarfordt et al. who reported about
nine patients with suprarenal obstructive calcifications of
the aorta [19, 20]. The frequency reported in the literature
ranges from 0.6% to 1.8% [20, 21]. Consecutive possible
symptoms are hypertension, intermittent claudication, and
visceral ischemia [20]. In most cases, the diagnosis is not
made until imaging is performed due to vascular compli-
cations [22]. Necessity of surgery is given in most cases,
depending on the exact localization and overall situation of
the patient. High operative mortality is associated with sur-
geries such as thromboendarterectomy, open surgery, bypass
surgery, or replacement of an aortic segment [19].
Teardrop sign of superior mesenteric vein
Surgical resection of pancreatic carcinomas is crucial for
survival. Tumor infiltration into adjacent vessels, especially
the superior mesenteric artery and vein, remains the most
important limitation for pancreaticoduodenectomy (Whip-
ple operation). Various imaging signs were evaluated with
Abdominal Radiology

regard to irresectability around the superior mesenteric vein,
including the “teardrop sign” (Fig. 8). This narrowing of
the superior mesenteric vein by carcinomas of the pancre-
atic head next to the confluence of the portal vein was first
described by Hough et al. [23]. The pathological change of
vessel configuration indicates an involvement in tumor or
venous obliteration. In addition to this tumor involvement of
more than half of the vessel circumference and wall irregu-
larities of the superior mesenteric artery and vein, this indi-
cates tumor infiltration and irresectability of the tumor [24].
With modern surgery techniques, pancreaticoduodenectomy
is also possible in borderline situations, however, the “tear-
drop sign” is still associated with the necessity of extensive
vascular reconstruction and poor prognosis [25].
Whirl‑pool sign
In CT examinations, the combined “whirl-pool-sign”
(Fig. 9) is often registered together with the coffee bean
sign [26]. The sign reflects the twisted mesenteric ves-
sels feeding the volvulus part of the colon. The “whirl
sign” was first described in 1981 by Fisher [27], who noted
that the superior mesenteric artery was twisted and sur-
rounded by bowel loops. Typically, with sonography it is
possible to identify the rotation of the small-bowel loops
and superior mesenteric vein (SMV) around the superior
mesenteric artery (SMA) [28]. Typically, the small-bowel
and SMV were rotated clockwise around the SMA. Sen-
sitivity of up to 90% for ultrasound is described in the
literature; however, CT is modality of choice.
Sandwich sign
In mesenteric lymphoma, the sandwich sign can be seen
in the transverse images of contrast-enhanced computed
tomography or ultrasound (Fig. 10). The mesenteric ves-
sels and the perivascular fat are reminiscent of sandwich
filling. In this context, the surrounding confluent lymph
nodes represent the two halves of the sandwich bun [29,
30]. Mesenteric lymphadenopathy can occur in different
diseases such as lymphoma, carcinoma, abdominal tuber-
culosis, or inflammatory bowel disease, however, they
do not produce large bulky adenopathy. The sandwich
sign is specific for mesenteric lymphoma causing large
bulky lymphomas enveloping fat, bowel, and vessels [31].
The most common cause producing this sign is a non-
Hodgkin´s lymphoma. As a rare condition, it can also be
seen in patients with post-transplant lymphoproliferative
disorder [32]. The sandwich sign is not specific, but it can
help in suggesting the diagnosis of lymphoma in order to
initiate an early and appropriate treatment.

Fig. 8  Teardrop sign. Enhanced

transversal CT images of
a 60-year-old male patient
with adenocarcinoma of the
pancreatic head in portalvenous
phase (arrows). Embedding of
the upper mesenteric vein with
teardrop configuration is shown

Fig. 9  Whirl sign. Enhanced

transversal (a) and coronal
(b) CT images of a 54-year-
old male patient showing the
typically twisted mesenteric
vessels (arrows) with associated
volvulus without any previous
operations or any underlying
disease. The diagnosis was
confirmed at surgery

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Fig. 10  Sandwich sign.
Enhanced coronal (a) and
transversal (b) CT images of a
55-year-old male patient with
mesenteric lymphoma. The
mesenteric vessel, the perivas-
cular fat, and the surrounding
lymph nodes (arrows) represent
the sandwich sign
Fig. 11  Nodule-in-Nodule sign. Contrast-enhanced CT of a 68-year-
old male patient with histologically proved HCC lesion (BCLC sta-
dium B). In the venous phase, hypervascular nodule (arrows) in the
central part of the HCC lesion is demarked
Signs in oncology
Nodule‑in‑nodule sign
Several imaging signs are associated with hepatocellular
carcinoma (HCC) in different imaging techniques. A well-
known sign is the “nodule-in-nodule” appearance of the
relatively small HCC in MRI (Fig. 11) as well as in other
imaging modalities [33, 34]. This imaging mark reflects
an area of increased arterial contrast enhancement in liver
parenchyma, in contrast to non-enhancing peripheral parts of
HCC lesion [35]. An often discussed theory is that “nodule-
in-nodule” sign within an HCC lesion may mark a part of
the tumor that has a different histological grading or differ-
entiation than the major part of the lesion. In particular, it is
suggested in early stage HCCs and degenerating dysplastic
nodules [36]. Moreover, in verified HCC lesions this could
show a dedifferentiation process from a well-differentiated
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Abdominal Radiology
to moderately differentiated HCC as proof of multistep hepa-
tocarcinogenesis [37].
Sister Mary Joseph sign
A well-known imaging sign in internal medicine, gyne-
cology, and radiology is the “Sister Mary Joseph sign”,
defined as a metastasis in the umbilicus [38, 39]. The sign
was named by Hamilton Bailey in 1960 after Sister Mary
Joseph who was the first person to detect it [40, 41]. Sister
Mary Joseph (1856–1939) worked as a surgical assistant,
first recognizing an umbilical nodule in a surgery as a veri-
fied sign of intraabdominal metastasis and then Hamilton
Bailey shaped the term “Sister Mary-Joseph nodule” [41].
It represents intraabdominal malignancy with ascites and
peritoneal carcinosis that extends into the umbilicus, often
with herniation (Fig. 12). In the literature, the most common
form is a spread per continuitatem from the peritoneum;
however, genesis by iatrogenic spread after laparoscopy is
also possible [41]. Classically, it is detected in the physi-
cal examination as a first hint of underlying cancer disease;
however, it can often be misinterpreted as simple hernia or
it is overseen . Various malignancies can be underlying, in
most cases adenocarcinomas of the gastrointestinal tract or
ovarian cancer [41]. It can be observed both in men and
women, however, a poor prognosis is always associated [41].
Omental cake
The abnormally thickened greater omentum is called omen-
tal cake (Fig. 13). The underlying pathology of this diffuse
peritoneal infiltration is most commonly the spread of an
intraperitoneal tumor which causes a diffuse or located
thickening of the omentum [42, 43]. Peritoneal metastases
most often originate from tumors from the ovary, stomach,
colon, pancreas, uterus, or bladder. Malignant melanoma
and breast and lung carcinoma can cause hematogenous
peritoneal metastases [44]. Less common conditions causing
Abdominal Radiology

Fig. 12  Sister Mary Joseph

sign. Contrast-enhanced com-
puted tomography of the abdo-
men of a 76-year-old female
patient with ovarian cancer and
advanced peritoneal carcinosis.
Sagittal (a) and axial (b) images
of the abdomen with ascites and
streaky peritoneal carcinosis.
Sister Mary Joseph nodule is
demarked (arrows) as a solid
peritoneal carcinosis nodule at
the umbilicus

Fig. 13  Omental cake. Enhanced transversal (a) and coronal (b) CT images of a 50-year-old male patient with tumor of the gastro-esophageal
junction. Ascites and a secondary peritoneal carcinosis is shown in the form of omental cake

an omental cake include primary tumors or inflammatory
conditions [42]. Primary tumors of the omentum include
benign entities such as leiomyomas or lipomas and malig-
nant tumors such as mesothelioma or fibrosarcoma [45].
Peritoneal tuberculosis is a rare inflammatory condition,
which is often hard to distinguish from peritoneal carcino-
matosis [46].
Claw sign
parenchyma. Hereby, the normal organ parenchyma encloses
the tumor like a claw.
The sign can be helpful in all modalities and all body
regions. In abdominal radiology, it is mainly used not only
for the tumors of kidneys (especially for Wilms tumor), but
also for the tumors of ovaries and uterus [47, 48]. Typical
examples in which the claw symbol is useful include the dif-
ferentiation of a Wilms tumor from a neuroblastoma [49] or
a renal angiomyolipoma from a retroperitoneal liposarcoma.

The claw sign is useful for differentiating whether a tumor
originates from an organ or other solid structure itself or
is located adjacent and only displaces it. Its name derives
from the sharp angles on both sides of the tumor formed
by the surrounding normal organ parenchyma (Figs. 14 and
15). These angles can only be detected if the tumor origi-
nates from the organ itself and displaces or thins out the
Thoraco‑abdominal junction
Upside–down stomach
Different forms of herniation of the stomach into the tho-
rax are possible. The rarest type of hiatal hernia is the
upside–down stomach (Fig. 16), with a complete or nearly

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 Abdominal Radiology

Figs.  14 and 15  Claw sign. Wilms tumor in a 2-year-old boy with the surrounding normal organ parenchyma. These angles can only be
typical claw sign (arrows). Contrast-enhanced T1-w MRI in axial detected if the tumor originates from the organ itself and displaces or
(a) and coronal (b) orientation. The claw sign can be seen here, thins out the parenchyma. Typically, it can help for the differentiation
derives from the sharp angles on both sides of the tumor formed by of a Wilms tumor from a neuroblastoma

Fig. 16  Upside–down stomach.
Posteroanterior (a) and lateral
(b) chest X-ray showed a large
herniation of almost the whole
stomach into the posterior
mediastinum in a 78-year-old
female patient (arrows). In the
enhanced computed tomogra-
phy in coronal (c) and axial (d)
images, the entire extent of the
gastric herniation with partial
rotation is demarked (arrows)

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Abdominal Radiology
Fig. 17  Water lily sign. Enhanced transversal CT images of a
25-year-old male patient with upper abdominal pain with demarked
cystic lesion in the liver. The cystic lesion shows a rim enhance-
ment; however, no structures within. In additionally performed MRI
complete herniation of the stomach into the posterior medi-
astinum [50, 51]. Other minor forms of migration are hiatal
hernia at the gastro-esophageal junction, paraesophageal
hernia of a minor part of the stomach, or a combination
of both [52, 53]. Also, an additional herniation beside the
upside-down stomach in form of an additional paraesoph-
ageal herniation through the hiatus or a secondary gap is
possible [54]. Various pathomechanisms or a combination
of them are possible for an upside-down stomach: besides
increased intraabdominal pressure, trauma including widen-
ing of the diaphragmatic hiatus or shortening of the esopha-
gus are potential reasons [51, 54]. The stomach is usually
fixed in the upper abdomen without the possibility of migra-
tion or volvulus. The most rigid point is the first part of
the duodenum in the retroperitoneum. This point regularly
limits a potential volvulus. Furthermore, a fixation between
gastrocolic and gastrosplenic ligaments is given [54]. Hence,
the stomach rather tends to organoaxial and mesenteroaxial
torsion than herniation into the posterior mediastinum [54].
Symptoms may include reflux and mechanically impaired
gastric emptying [55]. There is also an increased risk of
incarceration and volvulus development [55]. Imaging diag-
nosis is usually possible by fluoroscopy, computed tomog-
raphy, or radiographs.
Infection
Water lily sign describes the floating endocyst membrane
within a bigger fluid filed cyst mimicking the appearance
of a water lily. Typically it can be seen in hydatid infec-
tions on plain radiographs or on CT and MRI. In this con-
text it can divided into the outermost layer (is called peri-
cyst), the middle laminated membrane (which is acellular)
and third the inner membrane. The water lily sign is clas-
sically described on radiographics of the chest, however,
examination, floating membranes within the cyst were demarked in
T2-w images that mimic the appearance of a water lily. The water lily
sign is suggestive for Echinococcus granulosus infection which was
approved in the patient by serology
in cases of hydatid infections (Fig. 17), e.g., Echinococ-
cus granulosus, the water lily sign can be seen typically
in T2-weighted MRI imaging sequences [56]. A potential
detachment of the endocyst membrane results in floating
membranes within the main cyst that mimic the appear-
ance of a water lily [57]. Also, calcifications of the main
capsule were possible, described in about 25 percent of
all cases in the literature [58]. Free floating fragments in
a cyst were specific for echinococcosis. The cystic lesions
can be singular or multilocular. Even in CT examinations,
the cyst wall can be detected as a well-defined thin line
[58]. In T1-w sequences after contrast agent application
the membranes can be masked. Overall the water-lily sign
is seen in transitional stage between active and inactive
disease [59, 60].
Conclusion
In abdominal radiology, there are numerous memorable
imaging signs. These are often pathognomonic for a specific
disease and can therefore significantly simplify diagnosis.
The knowledge of these pictograms is therefore essential for
radiologists interested in abdominal imaging and should also
be addressed in training and further education.
Compliance with ethical standards 
Conflict of interest  The authors declares that they have no conflicts
of interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
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 Abdominal Radiology

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