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14 Signs on Plain Film
Ext. จรร ยาภรณณ พพฒนกกลเลรศ

“free air within the peritoneal cavity”
The most common cause is a perforation of
the abdominal viscus
– most commonly, a perforated ulcer
Soto JA, Lucey BC. (2009). Emergency Radiology: The
Requisites. Pg 305
Khan AN. (2014). Pneumoperitoneum Imaging. Medscape.

Pneumoperitoneum: The 14 Signs 1-3) RUQ/Liver signs on supine AXR: .

1) Anterior Subhepatic Space Free Air • Supine. RUQ/Liver sign 1 • Linear shape ed r a p l a m o m C or n with ensity d t a f Ind .

2) Doges Cap Sign/ Morrison’s Pouch Free Gas • Supine. Sharp lower lateral corner 3. Positioned inferior to the 11thrib 5. Triangular shaped 2. Concave lateral border outlining the medial border of the liver 4. RUQ/Liver sign 2 1. Positioned superior to the right kidney Morrison’s pouch = a potential space between the right Ind .

RUQ/ Liver sign 3 • Uneven density in geographical shape Ind .3) Air Anterior to Ventral Surface Liver • Supine.

4) Rigler’s Sign • Supine • Bowel wall outlined by intraluminal & extraluminal air (extraluminal = free peritoneal gas) • Both sides of bowel wall can be seen (red arrows) Ind .

5) Decubitus Abdomen Sign • Left lateral decubitus • Air-fluid level • White arrow = free air between the abdominal wall and the liver • Black arrow = free fluid in the peritoneum Ind .

6) Falciform Ligament Sign • Supine • Falciform ligament – connects the anterior abdominal wall to the liver – extends inferiorly beyond the liver → becomes round ligament – becomes outlined with air in a patient with free abdominal gas Ind .

7) The Football Sign • massively air-filled peritoneum Ind .

8) Continuous Diaphragm Sign • massive pneumoperitoneu m → sufficient air beneath the diaphragm • left & right hemidiaphragms contrasted by the free gas appear as a continuous structure Ind .

9) Double Bubble Sign • subdiaphragmatic gas under the left hemidiaphragm • 2 collections of overlapping gas – subdiaphragmatic free gas (under black arrow) – normal gas within the fundus of the stomach (under white arrow) Ind .

10) The Cupola Sign • Dome-like • Air accumulation beneath the central tendon of the diaphragm Ind .

11) Lesser Sac Gas • The lesser sac – positioned posterior to the stomach – usually a potential Note: spacearrow = White Cupola sign Ind .

12) The Triangle Sign • small triangles of free gas positioned between the large bowel and the flank Ind .

13) Abscess Gas • arrowed bubbles of gas NOT clearly contained within normal hollow abdominal viscus – NOT aligned in a linear fashion nor outline normal haustral features Ind .

it's NOT in the retroperitoneum Ind .14) Pneumoretroperitoneum • Air seen surrounding the lateral border of the kidney (retroperitoneal organs) • If the gas is seen to move in an erect and decubitus view.

Other Signs of Pneumoperitoneum Inverted Dolphins Urachus Leaping Ligamentum V Sign Sign Ind .

Others: Urachus Sign • Air contrasted urachus • Vertical line between bladder and umbilicus • Outline of medial umbilical ligament Ind .

Others: The “Inverted V” Sign • Supine • Free air outlining the lateral umbilical ligaments.1148/ coursing inferiorly and laterally from the umbilicus – Infants: umbilical arteries – Adults: inferior epigastric vessels http://dx. Ind 6230689 .151.

Others: Leaping Dolphins Sign • Air under hemidiaphragm and diaphragmatic muscle slips visible Ind .

28:728 doi:10.1056/NEJMicm0904627 Emerg Med J 2011.1136/emj.2010.098699 Ind .Others: Ligamentum Teres Sign • Extraluminal air in the fissure for the Ligamentum Teres • Linear density running along the inferior edge of the falciform ligament Picture: DOI: 10.

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 Ind .

Bray JF.wikiradiography.098699 . (1976). 362:2410. Issue 1: 45-46. Radiologic Signs of Pneumoperitoneum. (2010. Pneumoperitoneum.References • • • • • • • • Soto JA. April). Pneumoperitoneum Imaging. Images in emergency medicine. (1973. Siemers PI. 127:753-756. Am J Roentgeno. Issue 1.1136/emj.2010.28:728 doi:10. Pg 305. Emerg Med J 2011. The “inverted V” sign of pneumoperitoneum. Weiner CI. Dennis JM. (1984. (2011. Khan AN. Fuller MJ. N Engl J Med 2010. June 24). (2009). RSNA. Diaconis JN. WikiRadiography. April). (2014). May 27). Menuck L. 107. Website: http://www. 151. Lee CH. The “Inverted V”: A New Sign of Pneumoperitoneum. Pneumoperitoneum: Importance of Right Upper Quadrant Features. Vol. Emergency Radiology: The Requisites. Vol. Lucey BC. Medscape.

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