Case contributed by Dr Muna Mohammad Aljallaf


A 54 old female presented to the emergency department with history of epigastric discomfort that progressed to sudden severe generalized abdominal pain associated with anorexia, nausea and two episodes of vomiting later in the day. The patient had not open bowel or passed flatus that day. On examination, she was afebrile, normotensive and normal heart rate. The palpation of the abdomen revealed a distended, guard and board like rigid belly. The rectal exam was normal.

Patient Data

Age: 54 year old
Gender: Female

Pneumoperitoneum in erect chest and supine abdominal radiographs for a patient who had perforated viscus (perforated duodenal ulcer).

Upright chest x-ray: Free air under both diaphragmatic spaces. 

Supine abdominal x-ray: free air in Morison's pouch and Rigler's sign

Annotated image

Upright Chest X-Ray: Right and left sided free air under the diaphragmatic spaces. 

Supine Abdominal X-Ray: Free air in Morison's pouch and Rigler's sign

Case Discussion

Plain x-ray is an important initial radiographic assessment step for patients presenting with clinical manifestation of perforated viscus. The patient was hemodynamically stable hence, an optimal radiographic imaging technique was performed.

Proper technique requires the patient to remain in desired plane position for as little as 5 minutes and a supine abdominal radiograph along with either an erect chest or a left lateral decubitus radiograph is obtained.

Some of the pneumoperitoneum signs seen in radiographs - which were reported in literature - are illustrated in the current case presented:

  • right and left-sided free air under the diaphragmatic spaces
  • doge cap sign: radiolucent collection of free air in Morison’s pouch between the posterior hepatic edge and anterior aspect of the right kidney
  • Rigler's sign: the appearance of bowel walls on when they are outlined by intraluminal and extraluminal (peritoneal) air
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Case information

rID: 46042
Published: 20th Jun 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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