Presentation
27th week premature neonate with resolving hyaline membrane disease, shows sudden abdominal distension.
Patient Data
Supine radiograph clearly illustrates the lucent liver sign, liver edge sign, doge cap sign, Rigler sign of free intraperitoneal air.
Assisted erect radiograph demonstrates the cupola sign, continuous diaphragm sign, falciform ligament sign.
A shoot-through lateral x-ray in the right decubitus position reveals large amounts of free air layering to the left side.
Case Discussion
Laparotomy revealed a solitary ileal perforation.
Pneumoperitoneum is a surgical emergency, and hence its imperative to be familiar with a radiograph appearance of free intraabdominal air on erect, supine and lateral decubitus views. The importance of supine radiographic interpretation has been emphasized in neonates and infants where erect X-rays are seldom opted for.
Various signs have been described on supine and erect radiographs, namely
- copula sign - pathognomic on erect views only
- Rigler sign
- liver signs: anterior subhepatic linear air, Morrison pouch air (Doges cap sign), Lucent liver sign, liver edge sign
- football sign
- falciform ligament sign
- urachus sign
- coronary ligament outlined by air
- continuous diaphragm sign
- triangle sign
- dancing/Leaping dolphin sign at diaphragmatic muscle slips
- Inverted V sign
- scrotal air
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