Case contributed by Dr J Yeung


Acute abdominal pain.

Patient Data

Age: Elderly
Gender: Female

Abdominal x-ray

Abdominal x-ray demonstrates numerous loops of small bowel outlined by gas both within the lumen and free within the peritoneal cavity. There is also ascites, with mottled gas densities over bilateral paracolic gutters.

Annotated image


In a normal x-ray only the luminal surface (blue arrows) should be visible outlined by gas. The serosal surface (orange) should not be visible as it is normally in contact with other intra-abdominal content of similar density (other loops of bowel, omentum, fluid).  In this case gas abuts the serosal surface rendering it visible. 

As this film has been obtained supine (note absence of air-fluid levels), ascites pools in the paracolic gutters, with fluid mixed in with gas bubbles (green arrows). 

Case Discussion

Radiographic features of pneumoperitoneum include

  • double wall sign (a.k.a. Rigler sign)
  • telltale triangle sign
  • inverted V sign
  • urachus sign
  • doge's cap sign. 

This patient underwent emergency operation. Findings included large amount of faeculent fluid within the peritoneum causing peritonitis. The underlying cause was rupture of jejunal diverticula.

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Case information

rID: 14905
Case created: 4th Sep 2011
Last edited: 18th Dec 2015
Inclusion in quiz mode: Included

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