Pneumoperitoneum

Röntgen-Übersichtsaufnahme
des Abdomen in Rückenlage bei massiv freier Luft intraperitoneal. Man erkennt die Kontrastierung der Darmwand von luminal (innen) und peritoneal (außen): Rigler-Zeichen.
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Premature
newborn with respiratory distress syndrome and new abdominal distension on a ventilatorAXR cross-table lateral shows a distended abdomen with a huge amount of air between the anterior abdominal wall and the abdominal organs.The diagnosis was pneumoperitoneum in a patient with respiratory distress syndrome.
pediatricimaging.org • CC-by-nc-sa 4.0
Pneumoperitoneum
("freie Luft") in der Röntgenaufnahme des Abdomens in linker Seitenlage. Man erkennt den Leberrand (rote Pfeile), die Gasblase in der Bauchhöhle (grüne Pfeile) und einen Luft-Flüssigkeits-Spiegel (blaue Pfeile).
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Pneumoperitoneum
bei Sigmaperforation (iatrogen). Rigler-Zeichen: Luft an beiden Seiten der Darmwand. Hier jedoch sicher nicht zu übersehen.
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Dünndarmperforation
bei inkarzerierter Narbenhernie. Massiv freie intraabdominelle Luft mit Rigler-Zeichen in der Linkseitenlage gut zu sehen. Ileussituation. Es musste Dünndarm reseziert werden.
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Riglerzeichen
bei freier Luft: Die Darmwand ist vor allem im Bereich der rechten Kolonflexur von innen und außen durch Luft kontrastiert.
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Freie Luft im
Abdomen nach PEG-Anlage. In Rückenlage erkennt man die flächige Hypertransparenz und am Kolonrahmen das typische Rigler-Zeichen mit Kontrastierung der Darmwand von innen und aussen.
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Pneumoperitoneum
bei Sigmaperforation (iatrogen). Rigler-Zeichen: Luft an beiden Seiten der Darmwand. Hier jedoch sicher nicht zu übersehen.
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Freie Luft
bei Sigmaperforation
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Perforation
bei einer Koloskopie: Massiv freie Luft in der Bauchhöhle und sogar Austritt in die Weichteile der Bauchwand.
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Perforation
bei einer Koloskopie: Massiv freie Luft in der Bauchhöhle und sogar Austritt in die Weichteile der Bauchwand.
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Premature
newborn with abdominal distension after nasogastric tube placementSupine AXR (above) shows increased lucency in the upper abdomen. The cross-table lateral AXR (below) shows air between the anterior abdominal wall and the bowel. The nasogastric tube follows a very straight course and does not curve towards the stomach. Note on both views that the tip of the nasogastric tube does not project over the stomach. US performed subsequently showed the tip of the nasogastric tube was in the retroperitoneum and not in the stomach.The diagnosis was perforation of the esophagus during nasogastric tube placement. In the operating room the pneumoperitoneum was found to be due to an ileal perforation.
pediatricimaging.org • CC-by-nc-sa 4.0
Pneumoperitoneum
• Perforated diverticulitis with free gas in peritoneal and retroperitoneal spaces - Ganzer Fall bei Radiopaedia
Shah, V. Perforated diverticulitis with free gas in peritoneal and retroperitoneal spaces. Case study, Radiopaedia.org. (accessed on 25 Oct 2022) https://doi.org/10.53347/rID-88673 • CC by-nc-sa 3.0 (modified)
Subdiaphragmatic
free gas • Subdiaphragmatic free gas secondary to anastomotic leak - Ganzer Fall bei Radiopaedia
Knipe H, Subdiaphragmatic free gas secondary to anastomotic leak. Case study, Radiopaedia.org (Accessed on 15 Apr 2023) https://doi.org/10.53347/rID-25402 • CC by-nc-sa 3.0 (modified)
Newborn with
respiratory distress and new abdominal distension. CXR (left) shows massive pneumoperitoneum and right pneumothorax which outlines a mass in the lower right chest which is causing mediastinal shift to the left. Coronal CT with contrast of the chest (above right) shows liver herniating through a lateral defect in the diaphragm into the lower right chest and lying above the right diaphragm (below right).The diagnosis was congenital diaphragmatic hernia containing liver as outlined by pneumothorax and pneumoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
Infant with
crampy abdominal pain and a mass protruding from the rectum. AXR scout image (above left) shows a non-obstructive bowel gas pattern. AP image from the start of an air enema begun after manual reduction of the mass into the rectum (above right), shows the tip of the rectal catheter in contact with the mass in the rectum. AP image from later in the study (below left) shows the mass now in the transverse colon near the splenic flexure. Despite multiple attempts the intussusception could not be reduced further and the exam was ended when air was seen outlining the liver and both sides of the wall of the small bowel (Rigler’s sign)(below right). In the operating room the intussusception was reduced manually and a site of perforation could not be found.The diagnosis was ileocolic intussusception extending all the way out of the rectum, that could not be reduced successfully and which resulted in pneumoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
Premature
newborn with respiratory distress. CXR AP (above) shows increased lucency in the upper abdomen. Left lateral decubitus AXR (below) shows a large amount of free air between the abdominal wall and the liver.The diagnosis was pneumoperitoneum due to spontaneous intestinal perforation.
pediatricimaging.org • CC-by-nc-sa 4.0
Postoperatives
Pneumoperitoneum mit angehobenem Zwerchfell rechts und Rigler-Zeichen links.
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Premature
newborn on ventilator with abdominal distensionCross-table lateral AXR shows a large amount of free air superiorly in the abdomen outlining some of the bowel loops and compressing the rest posteriorly.The diagnosis was pneumoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
Premature
newborn with abdominal distensionSupine AXR shows increased lucency in the upper abdomen with clear demonstration of the football sign of the falciform ligament being outlined by free air.The diagnosis was pneumoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
Newborn with
esophageal atresia with abdominal distension after gastrostomy tube placement 1 week agoSupine AXR (left) shows a gastrostomy tube projecting appropriately over the stomach with a triangular lucency superior to the stomach. Left lateral decubitus AXR (above right) again shows the triangular lucency superior to the stomach but does not show air between the abdominal wall and liver. Cross-lateral AXR (below right) shows air between the anterior abdominal wall and liver. The diagnosis was pneumoperitoneum due to gastric perforation after gastrostomy placement. In the operating room the patient was found to have ischemic necrosis of the greater curvature of the stomach.
pediatricimaging.org • CC-by-nc-sa 4.0
Pneumoperitoneum
from an insufficient intestinal anastomosis.
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A case of
complicated emphysematous cholecystitis. Direct signs of pneumoperitoneum secondary to gallbladder perforation: free air in the right subdiaphragmatic space.
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Pneumoperitoneum
after surgery.
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Pneumoperitoneum
from an insufficient intestinal anastomosis.
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Preschooler
with abdominal pain. Upright CXR shows free air beneath the diaphragm. The diagnosis was pneumoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
Pneumoperitoneum
im Thoraxbild. Die freie "Luft" ist zwischen dem Oberrand der Leber (rote Pfeile) und dem Zwerchfell (grüne Pfeile) zu erkennen. Die blauen Pfeile zeigen auf den gasgefüllten Dickdarm (normal).
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Freie Luft im
Abdomen nach PEG-Anlage. In der Seitenlage ist die Luft neben der Leber nicht zu übersehen.
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Premature
newborn after nasogastric tube placementSupine and left lateral decubitus AXR (left) show a nasogastric tube with its tip deep in the pelvis without evidence of free air. Supine AXR taken after pulling the nasogastric tube back into the stomach (above right) shows increased lucency throughout the central abdomen and left lateral decubitus AXR taken at same time (below right) shows air between the abdominal wall and the liver.The diagnosis was pneumoperitoneum due to gastric perforation during nasogastric tube placement which became visible only after the nasogastric tube was pulled out of the hole it had made in the stomach wall.
pediatricimaging.org • CC-by-nc-sa 4.0
Newborn with
distended abdomen after nasogastric tube placementSupine AXR (left) shows a large amount of air within the abdomen and air outlining both sides of bowel wall (Rigler’s sign) in the right lower quadrant. Supine AXR taken later after pulling back of the nasogastric tube out of the stomach shows visualization of the falciform ligament over the spine (American football sign)The diagnosis was pneumoperitoneum due to gastric perforation during nasogastric tube placement.
pediatricimaging.org • CC-by-nc-sa 4.0
Newborn who
suffered a profound hypoxic event after being discharged home. AXR AP (above) shows a large oval lucency in the midline of the upper abdomen. Cross table lateral AXR (below) shows a large amount of air between the abdominal wall and the liver. There is also air outlining both sides of the bowel wall of a loop of bowel (Rigler’s sign).The diagnosis was pneumoperitoneum due to small bowel perforation due to bowel ischemia from the hypoxic event.
pediatricimaging.org • CC-by-nc-sa 4.0
Pneumoperitoneum
from an insufficient intestinal anastomosis. Hardly to see in this image, but see CT.
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nicht verwechseln mit: properitonealer Fettstreifen / Chilaiditi-Syndrom
Radiopaedia • CC-by-nc-sa 3.0 • de

Pneumoperitoneum describes gas within the peritoneal cavity, often due to critical illness. There are numerous causes and several mimics.

Pathology

The most common cause of pneumoperitoneum is the disruption of the wall of a hollow viscus. In children, the causes are different from the adult population and are considered in the neonatal pneumoperitoneum article.

The causes and, hence, the corresponding severity of accompanying illness, are variable:

Radiographic features

Plain radiograph
Chest radiograph

An erect chest x-ray is probably the most sensitive plain radiograph for the detection of free intraperitoneal gas. If a large volume pneumoperitoneum is present, it may be superimposed over a normally aerated lung with normal lung markings.

Abdominal radiograph

Free gas within the peritoneal cavity can be detected on an abdominal radiograph. The signs created by the free intraperitoneal air can be further divided by anatomical compartments in relation to the pneumoperitoneum:

Ultrasound

Maybe useful in the appropriate clinical setting. A linear-array transducer (10-12 MHz) is considered more sensitive than a standard curvilinear abdominal transducer (2-5 MHz).

Recognized direct features include:

  • enhancement of the peritoneal stripe (peritoneal stripe sign)
    • either alone or associated with repeating, horizontal long-path reverberation artifacts which extend into the far field
  • discrete, hyperechoic foci representing gas bubbles
    • may adopt a linear arrangement, often associated with short path reverberation artifacts which appear as comet tails, or if tapering, ring down artifacts
    • may also cluster in a manner that results in the attenuation and diffuse reflection of reflected ultrasound waves, which results in an underlying inhomogenous (or dirty) acoustic shadow

Ultrasonography may also be combined with dynamic maneuvers

  • free intraperitoneal air is expected to demonstrate movement with patient position
  • it may also be displaced with caudal pressure on the probe above the collection, reappearing with cessation of the pressure
  • unlike air within the lung, does not demonstrate respirophasic changes

Differential diagnosis

See also

Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Pneumoperitoneum:
Pneumoperitoneum
beim Neugeborenen
Wikipedia • CC BY-SA 4.0
Pseudopneumoperitoneum
 
Wikipedia • CC BY-SA 3.0
Rigler-Zeichen
 
Wikipedia • CC BY-SA 4.0
Pneumothorax
 
Wikipedia • CC BY-SA 4.0
abnormales
Gas im Abdomen
Wikipedia • CC BY-SA 4.0
freie
retroperitoneale Luft
insightsimaging.springeropen.com • Open Access
Linksseitenlage
 
Wikipedia • CC BY-SA 3.0
Appendizitis
 
Wikipedia • CC BY-SA 3.0
Magenulkus
 
www.eurorad.org • CC by-nc-sa-4.0
mechanischer
Ileus
Wikipedia • CC BY-SA 4.0
Fremdkörper
 
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Nekrotisierende
Enterokolitis
pediatricimaging.org • CC-by-nc-sa 4.0
Mesenterialinfarkt
 
Wikipedia • CC BY-SA 4.0
Divertikulitis
 
Wikipedia • CC BY-SA 4.0
Mediastinalemphysem
 
Wikipedia • CC BY-SA 4.0
peritoneal
cavity
Wikipedia • Public domain