Tension pneumoperitoneum

Case contributed by Dr Ameya Kulkarni


History of per rectal instrumentation with pneumatic tools followed by sudden onset pain in abdomen.

Patient Data

Age: 35 years
Gender: Male

There is gross pneumoperitoneum with all the abdominal viscera pushed towards center, indicative of a degree of tension. 


Non-contrast study of abdomen shows presence of a large amount of gas in the peritoneal cavity with the falciform ligament seen prominently. These findings support a diagnosis of large volume pneumoperitoneum. 

Case Discussion

It is possible, by careful radiographic technique, to demonstrate as little as 1 ml of free gas on erect chest or left lateral decubitus abdominal films. However, radiographic technique and positioning are important and a patient should be in position for 10 minutes before the film is taken, as it takes time for free gas to rise to the highest point in the abdomen.

Classic radiograph findings of pneumoperitoneum include:

  • Rigler sign: visualization of the outer and inner wall of a loop of bowel
  • Cupola sign: relatively large amounts of gas may accumulate beneath the diaphragm, or in the center of the abdomen over a fluid collection (the so-called "football sign")

CT is, however, the most sensitive method for the detection of peritoneal free gas, with even tiny bubbles of gas being visible.

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