Ext.

จริ ยาภรณ์ พัฒนกุลเลิศ

 “ within the peritoneal cavity”
The most common cause is a perforation of the
abdominal viscus
– most commonly, a

Soto JA, Lucey BC. (2009). Emergency Radiology: The Requisites. Pg 305
Khan AN. (2014). Pneumoperitoneum Imaging. Medscape.
1-3) RUQ/Liver signs on supine AXR: 9) Double Bubble Sign
• Anterior Subhepatic Space Free Air
• Doges Cap Sign 10) Cupola Sign
• Air Anterior to Ventral Surface of Liver
11) Lesser Sac Gas
4) Rigler’s Sign
12) Triangle Sign
5) Decubitus Abdomen Sign
13) Abscess Gas
6) Falciform Ligament Sign

7) Football Sign 14) Pneumoretroperitoneum

8) Continuous Diaphragm Sign 15) Others

• Supine; RUQ/Liver sign 1
• Linear shape

Index
 • 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
Index
• Supine; RUQ/ Liver sign 3
• Uneven density in

Index
• Supine
• Bowel wall

(extraluminal = free
peritoneal gas)
of bowel wall
can be seen
(red arrows)

Index
• Left lateral
decubitus
• Air-fluid level

between
the abdominal
wall and the liver

in the
peritoneum

Index
• 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 gas

Index
• massively air-filled
peritoneum

Index
• massive
pneumoperitoneum
→ sufficient air
beneath the
diaphragm
• left & right
hemidiaphragms
contrasted by the
free gas appear as a

Index
• subdiaphragmatic gas
under the left
hemidiaphragm

– subdiaphragmatic free
gas (under black arrow)
– normal gas within the
fundus of the stomach
(under white arrow)

Index
• Air accumulation
beneath the central
tendon of the
diaphragm

Index
• The lesser sac
– positioned posterior to
the stomach
– usually a potential space

Note:
White arrow = Cupola sign

Index
• small triangles of free
gas positioned between
the large bowel and the
flank

Index
• arrowed
NOT clearly contained
within normal hollow
abdominal viscus
– NOT aligned in a linear
fashion nor outline
normal haustral features

Index
• 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

Index
 Inverted V
Urachus Sign
Sign

Leaping Ligamentum
Dolphins Sign Teres Sign

Index
• Air contrasted urachus
• Vertical line between
bladder and umbilicus
• Outline of medial
umbilical ligament

Index
 • 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.151.1.6230689
Index
• Air under
hemidiaphragm and
diaphragmatic muscle
slips visible

Index
 • Extraluminal air in the
fissure for the
Ligamentum Teres
• Linear density running
along the inferior edge of
the falciform ligament

Picture: DOI: 10.1056/NEJMicm0904627 Emerg Med J 2011;28:728

doi:10.1136/emj.2010.098699
Index
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

Index
• Soto JA, Lucey BC. (2009). Emergency Radiology: The Requisites. Pg 305.
• Khan AN. (2014). Pneumoperitoneum Imaging. Medscape.
• Fuller MJ. (2011, May 27). Pneumoperitoneum. WikiRadiography.
Website: http://www.wikiradiography.com/page/Pneumoperitoneum
• Menuck L, Siemers PI. (1976). Pneumoperitoneum: Importance of Right
Upper Quadrant Features. Am J Roentgeno. 127:753-756.
• Weiner CI, Diaconis JN, Dennis JM. (1973, April). The “Inverted V”: A New
Sign of Pneumoperitoneum. RSNA. Vol. 107, Issue 1.
• Bray JF. (1984, April). The “inverted V” sign of pneumoperitoneum. RSNA.
Vol. 151, Issue 1: 45-46.
• Lee CH. (2010, June 24). Radiologic Signs of Pneumoperitoneum. N Engl J
Med 2010; 362:2410.
• Images in emergency medicine. Emerg Med J 2011;28:728
doi:10.1136/emj.2010.098699