Tension pneumoperitoneum

Case contributed by Dr Rubeena Ali
Diagnosis certain


Acute onset abdominal pain after per rectal instrumentation with pneumatic tool. On examination abdomen was tense and tender with absent bowel sounds.

Patient Data

Age: 18 years
Gender: Male

Chest x-ray


X-ray chest (erect) done after keeping the patient in a standing position for 10 minutes.

It shows free air under bilateral hemidiaphragms with continuous diaphragm sign. Bilateral hemidiaphragms are also raised secondary to increased intraabdominal pressure.

Abdominal x-ray


On supine view, an ovoid lucency is noted overlying the abdomen suggestive of the football sign.

On erect view, massive free intraperitoneal air is noted causing central displacement of upper abdominal viscera and downward displacement of the bowel loops.

Case Discussion

Tension pneumoperitoneum is a surgical emergency. It can occur secondary to iatrogenic injury during endoscopy, pneumothorax in patients on mechanical ventilation, and also in cases of per rectal instrumentation by pneumatic tools.

It leads to increase intraabdominal pressure and elevation of diaphragm with resultant reduced volume of the thoracic cavity. Also compression of large abdominal vessels can lead to hemodynamic instability.

Radiographic diagnosis is almost always certain. On x-ray, findings include:

  • large volumes of free intraperitoneal gas displacing the abdominal viscera towards the center of the abdomen on erect abdominal x-ray

  • football sign on supine abdominal x-ray

  • continuous diaphragm sign on chest x-ray

As it is life threatening, so immediate surgical intervention is required which is usually needle decompression followed by exploratory laparotomy.

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