Rigler sign and pneumatosis intestinalis

Case contributed by RMH Core Conditions
Diagnosis certain


One day of abdominal distension and pain.

Patient Data

Age: 85 years
Gender: Male

Markedly distended small bowel loops throughout the abdomen with air-fluid levels in keeping with small bowel obstruction. There is evidence of pneumatosis. Rigler sign indicates free intraperitoneal gas.

Annotated image
  • red arrows = pneumatosis intestinalis
  • yellow arrows = Riger sign

Extensive diffuse small bowel dilatation. In the mid to distal ileum, there are small bowel feces within abnormally dilated bowel. Distal to this, a intraluminal V shaped hyperdense object is present at a transition point. The colon is also collapsed.

There is a moderate amount of free intraperitoneal gas predominantly in the upper abdomen with small bubbles also seen between liver and diaphragm. Segmental pneumatosis is present particularly in the right upper quadrant, and also within the pelvis. Segments without pneumatosis do have an enhancing thin bowel wall. There is no portal venous or mesenteric venous gas. Mesenteric arteries are widely patent.

Small amount of free intraperitoneal fluid.


  1. Small bowel obstruction with intraluminal FB in the distal ileum.
  2. Diffuse pneumatosis of small bowel and free intraperitoneal gas.

Case Discussion

The patient went onto theater and had a small bowel resection with removal of the foreign body, and eventually recovered from this episode. 

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