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. Pneumoperitoneum is most often caused by perforated abdominal viscus and can present an acute medical emergency. 

“The Radiological signs of pneumoperitoneum are among the most important signs in radiology, indeed in Medicine. Sometimes the amount of free gas is small and you may have to work to demonstrate it (i.e. modify the film technique). Miss it and the patient may die”

???????

CASE REVIEW

A 51-year-old man presented to the ED with progressive abdominal pain of one day's duration. He had not eaten all day and had vomited twice. There was no associated diarrhea or melena.

He had a history of alcoholic hepatitis, COPD, and surgical repair of a colonic-bladder fistula 10 years earlier. He had mild constipation and abdominal discomfort for the past few months.

On examination, the patient was in moderate distress due to abdominal pain. Vital signs: blood pressure 130/70 mm Hg; pulse 118 beats/min; respirations 24 breaths/min; temperature 100.8º F (rectal).

His abdomen was distended but soft, with mild diffuse tenderness and no rebound tenderness. His stool was negative for occult blood. He was anicteric

The best radiographic view for detecting free intraperitoneal air is the upright chest radiograph

Look 4 air

• Anterior subhepatic space free air• Morrison’s pouch• Air anterior to ventral surface of liver• Decubitus abdomen sign• Rigler’s sign on supine• Falciforme ligament sign• The “football “signe Air

• Continuous Diaphragm sign• Double bubble sign• The Cupola sign• Lesser sac gas• The triangle sign• Pneumoretroperitoneum

RUQ LIVER SIGNS

DECUBITUS ABDOMEN SIGN

RIGLER’S SIGN SUPINE AXR

FALCIFORME LIGAMENT SIGN

THE FOOTBALL SIGN

CONTINUOUS DIAPHRAGM SIGN

THE DOUBLE BUBBLE SIGN

CUPOLA SIGN

THE TRIANGLE SIGN

NEUMORETROPERITONEO

“We diagnose what we look for and look for what we know”