Presentation
The patient presents with severe and acute abdominal distension with respiratory distress.
Patient Data
Elevated BMI and consequent body habitus. There is a tension pneumoperitoneum with inferiorly displaced bowel loops and an elevated diaphragm. There is cardiomegaly, magnified on a portable and supine frontal series.
There is significant abdominal distension secondary to a large tension pneumoperitoneum.
There is a large volume of free intraperitoneal air, with consequent lateral abdominal wall distension, superior displacement of the diaphragms, and posteroinferior displacement of the solid abdominal organs including hollow visceral organs. The stomach is collapsed with a satisfactorily sited nasogastric tube. Significantly reduced IVC caliber suggesting decreased venous return and likely reduced cardiac output. There is no free intra-abdominal or intrapelvic fluid.
Scattered diverticulosis, with perigastric and pericolonic inflammatory reaction surrounding the splenic flexure with regional gaseous locules, and a suspicion of a likely gastric and/or splenic flexure perforation and acute diverticulitis. The small bowel appears normal and unobstructed.
Multichamber cardiomegaly. Calcified coronary vascular plaque including ventricular outflow track. Physiological superior mediastinal fluid. Bibasilar collapse/ consolidation/ atelectasis.
Multiple irregular splenuncles/ splenosis identified, post previous splenectomy. There is no biliary obstruction, and no calcific cholelithiasis. The renal tracts appear normal. The appendix is present and identified and normal. There is no abdominal or pelvic lymphadenopathy. Dorso lumbar and lumbosacral degenerative change with no occult bony lesions.
Case Discussion
An example of a tension pneumoperitoneum in an adult patient. The patient was self-medicating with analgesics with a background of dental sepsis and pain. Surgical confirmation of complicated peptic ulcer disease with a dual gastric ulcer and perforation as a source of the tension pneumoperitoneum. The patient had an uneventful recovery post-surgical management. The combined plain films, CT scanogram and CT imaging demonstrate the leaping dolphin sign (on portable supine chest frontal series), cupola sign, continuous diaphragm sign (CT scanogram), Rigler's sign, football sign, falciform ligament sign (CT scan), hepatic edge sign, lucent liver sign, and Doge cap sign (supine abdominal X-ray and CT scanogram).
Reviewing the CT abdomen and pelvis on lung and bone windows is recommended to assess for free air, this will often assist in identifying tiny pockets of free air in cases of subtle perforation or necrotic sepsis. In this instance, there is significant free intraperitoneal air and the lung and bone windows just confirm the tension pneumoperitoneum and offer minimal additional information.
The tension pneumoperitoneum on axial CT has a very similar appearance to a tension pneumocephalus and the Mount Fuji sign and in this instance, the falciform ligament splits the mountain.
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