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History :
A 77-year-old man suffered from sudden onset abdominal pain. The pain was initially located in the epigastric region, but became diffuse later. The patient had tarry stool history.
Questions:
- What are the findings?
- What is the diagnosis?
Discussion :
Large collection of gas:
-abdominal distension, no gastric air-fluid level
-"football sign" = large pneumoperitoneum outlining entire abdominal cavity
-"double wall sign" = "Rigler sign" = "bas-relief sign" = air on both sides of bowel as intraluminal gas + free air outside (usually requires >1,000 mL of free intraperitoneal gas + intraperitoneal fluid)
-"telltale triangle sign" = triangular air pocket between 3 loops of bowel
-depiction of diaphragmatic muscle slips = two or three 6-13 cm long and 8-10 mm wide arcuate soft-tissue bands directed vertically inferiorly + arching parallel to diaphragmatic dome superiorly
-outline of ligaments of anterior inferior abdominal wall:
--"inverted V sign" = outline of both lateral umbilical ligaments (containing inferior epigastric vessels)
--outline of medial umbilical ligaments (obliterated umbilical arteries)
--"urachus sign" = outline of middle umbilical ligament
RUQ gas (best place to look for small collections):
-single large area of hyperlucency over the liver
-oblique linear area of hyperlucency outlining the posteroinferior margin of liver
-doge's cap sign = triangular collection of gas in Morison pouch (posterior hepatorenal space)
-outline of falciform ligament = long vertical line to the right of midline extending from ligamentum teres notch to umbilicus; most common structure outlined
-ligamentum teres notch = inverted V-shaped area of hyperlucency along undersurface of liver
-ligamentum teres sign = air outlining fissure of ligamentum teres hepatis (= posterior free edge of falciform ligament) seen as vertically oriented sharply defined slitlike / oval area of hyperlucency between 10th and 12th rib within 2.5-4.0 cm of right vertebral border 2-7 mm wide and 6-20 mm long
-"saddlebag / mustache / cupola sign" = gas trapped below central tendon of diaphragm
-parahepatic air = gas bubble lateral to right edge of liver
