Frontal chest X-ray. The air bubble below the right hemidiaphragm (on the left of the image) is a pneumoperitoneum.
SpecialtyGastroenterology Edit this on Wikidata

Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

Spontaneous pneumoperitoneum is a rare case that is not caused by an abdominal organ rupture. This is also called an idiopathic spontaneous pneumoperitoneum when the cause is not known.

In the mid-twentieth century, an "artificial" pneumoperitoneum was sometimes intentionally administered as a treatment for a hiatal hernia. This was achieved by insufflating the abdomen with carbon dioxide. The practice is currently used by surgical teams in order to aid in performing laparoscopic surgery.


Spontaneous pneumoperitoneum

A spontaneous pneumoperitoneum is a rare case that is not caused by an abdominal organ rupture. This is also called an idiopathic spontaneous pneumoperitoneum when the cause is not known.[16] Causes of a spontaneous pneumoperitoneum, with no peritonitis include a barotrauma due to mechanical ventilation, and a tracheal rupture following an emergency intubation. In the ventilation case, air had passed from the chest into the abdominal cavity through the diaphragm. In the tracheal rupture air had passed along the great vessels.[17]


When present, pneumoperitoneum can often be seen on projectional radiography, but small amounts are often missed, and CT scan is nowadays regarded as a criterion standard in the assessment of a pneumoperitoneum.[18] CT can visualize quantities as small as 5 cm3 of air or gas.

Signs that can be seen on projectional radiography are shown below:

The double wall sign marks the presence of air on both sides of the intestine.[19] However, a false double wall sign can result from two loops of bowel being in contact with one another.[20] The sign is named after Leo George Rigler.[21] It is not the same as Rigler's triad.

The football sign is when the abdomen appears as a large oval radiolucency reminiscent of an American football on a supine projectional radiograph.[22] The football sign is most frequently seen in infants with spontaneous or iatrogenic gastric perforation causing pneumoperitoneum. It is also seen in bowel obstruction with secondary perforation, as in Hirschprung disease, midgut volvulus, meconium ileus and intestinal atresia. Iatrogenic causes like endoscopic perforation may also give football sign.[citation needed]

The Cupola sign is seen when air is accumulated under the central tendon of the diaphragm.[23]

Differential diagnosis

As differential diagnoses, a subphrenic abscess, bowel interposed between diaphragm and liver (Chilaiditi syndrome), and linear atelectasis at the base of the lungs can simulate free air under the diaphragm on a chest X-ray.[citation needed]


Treatment depends on the cause of the condition.[citation needed]


Pneumoperitoneum can be described as peritoneal emphysema,[25] just as pneumomediastinum can be called mediastinal emphysema, but pneumoperitoneum is the usual name.

See also


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  2. ^ "Large Bowel Obstruction". The Lecturio Medical Concept Library. Retrieved 10 August 2021.
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  4. ^ "diverticulum | Definition of diverticulum in English by Lexico Dictionaries". Lexico Dictionaries | English. Archived from the original on July 17, 2019. Retrieved 2019-07-17.
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  6. ^ "Megacolon". The Lecturio Medical Concept Library. Retrieved 10 August 2021.
  7. ^ Necrotizing Enterocolitis Bugs, Drugs and Things That Go Bump in the Night
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  13. ^ Kizer KW (May 1980). "Medical hazards of the water skiing douche". Annals of Emergency Medicine. 9 (5): 268–9. doi:10.1016/s0196-0644(80)80387-8. PMID 7369581. Many injuries can result from water skiing accidents, but the water skiing "douche" is unique to this sport. Although generally causing only discomfort, significant trauma can result from the forceful entry of water into the various body orifices.
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  22. ^ Rampton JW (April 2004). "The football sign". Radiology. 231 (1): 81–2. doi:10.1148/radiol.2311011290. PMID 14990817.
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