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.