Signs in pneumoperitoneum

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 Supine; RUQ/Liver sign 1
 Linear shape
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 Supine; RUQ/Liver sign 2
shaped
lateral
corner
border outlining the
medial border of the
liver
4. Positioned inferior to
the 11thrib
5. Positioned superior
to the right kidney
Morrison’s pouch =
a potential space between
the right kidney & the liver
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 Supine; RUQ/ Liver sign 3
 Uneven density in
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 Supine
 Bowel wall
(extraluminal = free
peritoneal gas)
of bowel
wall can be seen
(red arrows)
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 Left lateral
decubitus
 Air-fluid level
between
the abdominal
wall and the liver
in the
peritoneum
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 Supine
 Falciform ligament
 connects the anterior
abdominal wall to the
liver
 extends inferiorly
beyond the liver →
becomes round
ligament
 becomes
in a patient
with free abdominal
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 massively air-filled
peritoneum
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 massive
pneumoperitoneum
→ sufficient air
beneath the
diaphragm
 left & right
hemidiaphragms
contrasted by the
free gas appear as a
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 subdiaphragmatic gas
under the left
hemidiaphragm
 subdiaphragmatic
free gas (under black
arrow)
 normal gas within the
fundus of the stomach
(under white arrow)
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 Air accumulation
beneath the central
tendon of the
diaphragm
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 The lesser sac
 positioned posterior to
the stomach
 usually a potential
space
Note:
White arrow = Cupola
sign
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 small triangles of free
gas positioned
between the large
bowel and the flank
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 arrowed
NOT clearly contained
within normal hollow
abdominal viscus
 NOT aligned in a linear
fashion nor outline
normal haustral features
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 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
in the
retroperitoneum
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Urachus Sign
Inverted V
Sign
Leaping
Dolphins Sign
Ligamentum
Teres Sign
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 Air contrasted
urachus
 Vertical line between
bladder and umbilicus
 Outline of medial
umbilical ligament
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 Supine
 Free air outlining the
, coursing
inferiorly and laterally
from the umbilicus
 Infants: umbilical
arteries
 Adults: inferior
epigastric vessels
http://dx.doi.org/10.1148/radiology.151.1.62306
89
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 Air under
hemidiaphragm and
diaphragmatic muscle
slips visible
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 Extraluminal air in the
fissure for the
Ligamentum Teres
 Linear density running
along the inferior edge of
the falciform ligament
Emerg Med J 2011;28:728
doi:10.1136/emj.2010.098699
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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
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Signs in pneumoperitoneum

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