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Other names: Aeroperitoneum[1]
Chest X-ray with air between the right diaphragm and the liver (green and red arrows). Air also visible below the diaphragm on the persons left. Blue arrows mark a normal gas filled colon.
SpecialtyGeneral surgery
SymptomsNone to peritonitis[2]
ComplicationsAbdominal compartment syndrome[3]
CausesGastrointestinal tract perforation, abdominal surgery, peritoneal dialysis, pneumothorax, pneumomediastinum, mechanical ventilation, entry via the vagina[1][4]
Diagnostic methodX-ray, CT scan[2]
Differential diagnosisChilaiditi syndrome, pneumomediastinum, atelectasis of the lower lung, bowel wall gas[5]
TreatmentBased on cause, often surgery[6][4]

Pneumoperitoneum is the presence of air or other gas in the peritoneal cavity.[1] Symptoms may vary from none to peritonitis.[2] Other symptoms may include abdominal swelling or shortness of breath.[2] Complications may rarely include abdominal compartment syndrome.[3]

The most common cause (>90%) is a hole in the gastrointestinal tract.[1][4] This may occur due to a peptic ulcer, bowel obstruction, appendicitis, or abdominal trauma.[1] Other causes may include following abdominal surgery, including laparoscopic surgery; peritoneal dialysis, pneumothorax, pneumomediastinum, mechanical ventilation, and entry via the vagina.[1] Rarely cases may occur due to an unknown cause.[4] Diagnosis is generally via X-ray or CT scan.[2]

Treatment depends on the source of the air.[6] In most cases surgery is required; though certain cases may be managed conservatively.[4][7] Conservative management may include bowel rest, intravenous antibiotics, and closely watching for worsening.[2] Cases were detected via X-ray as early as 1915.[4]

Signs and symptoms

The presentation often involves:[8]



Spontaneous cases are rare and not caused by an abdominal organ rupture. This is called idiopathic when the cause is not known.[24] Causes of a spontaneous pneumoperitoneum, with no peritonitis include barotrauma due to mechanical ventilation, and 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.[25]


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.[26] 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.[27] However, a false double wall sign can result from two loops of bowel being in contact with one another.[28] The sign is named after Leo George Rigler.[29] 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.[30] 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.[31]

Differential diagnosis

Pseudopneumoperitoneum a) Chest radiograph of Chilaiditi syndrome showing large bowel loops arrow under the diaphragm b) linear atelectasis c) loculated air beneath the diaphragms following colonoscopy[5]

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.


Pneumoperitoneum can be described as peritoneal emphysema,[33] just as pneumomediastinum can be called mediastinal emphysema, but pneumoperitoneum is the usual name.

See also


  1. 1.0 1.1 1.2 1.3 1.4 1.5 Jones, Jeremy. "Pneumoperitoneum | Radiology Reference Article |". Radiopaedia. Archived from the original on 2 February 2023. Retrieved 31 January 2023.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 Ramponi, DR (2018). "Pneumoperitoneum". Advanced emergency nursing journal. 40 (2): 87–93. doi:10.1097/TME.0000000000000189. PMID 29715250.
  3. 3.0 3.1 Eltorai, Adam E. M.; Hyman, Charles H.; Healey, Terrance T. (18 December 2019). Essential Radiology Review: A Question and Answer Guide. Springer Nature. p. 306. ISBN 978-3-030-26044-6. Archived from the original on 2 February 2023. Retrieved 31 January 2023.
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Williams, NM; Watkin, DF (September 1997). "Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas". Postgraduate medical journal. 73 (863): 531–7. doi:10.1136/pgmj.73.863.531. PMID 9373590.
  5. 5.0 5.1 Jones, Jeremy. "Pseudopneumoperitoneum | Radiology Reference Article |". Radiopaedia. Archived from the original on 2 February 2023. Retrieved 31 January 2023.
  6. 6.0 6.1 Tanner, TN; Hall, BR; Oran, J (October 2018). "Pneumoperitoneum". The Surgical clinics of North America. 98 (5): 915–932. doi:10.1016/j.suc.2018.06.004. PMID 30243453.
  7. Mularski, RA; Sippel, JM; Osborne, ML (July 2000). "Pneumoperitoneum: a review of nonsurgical causes". Critical care medicine. 28 (7): 2638–44. doi:10.1097/00003246-200007000-00078. PMID 10921609.
  8. Martin, Ronald F.; Schenarts, Paul J. (24 September 2018). Emergency General Surgery, An Issue of Surgical Clinics. Elsevier Health Sciences. ISBN 978-0-323-64100-5. Archived from the original on 4 August 2022. Retrieved 28 July 2022.
  9. "Peptic Ulcer Disease". The Lecturio Medical Concept Library. Archived from the original on 10 August 2021. Retrieved 10 August 2021.
  10. "Large Bowel Obstruction". The Lecturio Medical Concept Library. Archived from the original on 11 July 2021. Retrieved 10 August 2021.
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  12. "diverticulum | Definition of diverticulum in English by Lexico Dictionaries". Lexico Dictionaries | English. Archived from the original on 2021-11-02. Retrieved 2019-07-17.
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  14. "Megacolon". The Lecturio Medical Concept Library. Archived from the original on 27 July 2021. Retrieved 10 August 2021.
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