Advanced Emergency Nursing Journal

Vol. 40, No. 2, pp. 87–93

Copyright 
C 2018 Wolters Kluwer Health, Inc. All rights reserved.

Imaging
Column Editor: Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN

Pneumoperitoneum
Denise R. Ramponi, DNP, FNP-C, ENP-BC, FAEN, FAANP, CEN

Abstract
Pneumoperitoneum, usually seen as free air under the diaphragm, is a finding that can be seen on
plain abdominal radiographs, signifying a leakage of air, usually from a perforation in the gastroin-
testinal tract. There are several other potential pathways from other body compartments for air to
enter the abdominal cavity. Pneumoperitoneum does not always signify bowel rupture, as it can also
result from pneumomediastinum and pneumothorax, and in patients who are being mechanically
ventilated. Patient history and physical examination can assist in a preliminary diagnosis before di-
agnostic imaging. Plain chest/abdominal radiograph or computed tomographic scan of the abdomen
can be diagnostic of pneumoperitoneum. Surgical versus nonsurgical conservative observation is
determined on the basis of the cause and amount of free air. Key words: abdominal free air, benign
pneumoperitoneum, free air under diaphragm, intraperitoneal air, mottled air sign, pneumomedi-
astinum, pneumoperitoneum, retroperitoneal air, Rigler’s sign, tension pneumoperitoneum

TERMS PATIENT HISTORY

Pneumoperitoneum: Free air within the Salient points of the patient history to be col-
peritoneal cavity lected include any concurrent medical con-
Benign pneumoperitoneum: Asymptoma- ditions such as gastric or duodenal ulcer, ir-
tic free intra-abdominal air in the abd- ritable bowel disease, and diverticulitis that
omen can lead to pneumoperitoneum from gastroin-
Tension pneumoperitoneum: Free intra- testinal (GI) perforations. Recent surgical pro-
peritoneal air in the abdomen under pres- cedures, mechanical ventilation, trauma ex-
sure that compromises blood flow and posure, or other invasive procedures can lead
visceral function to pneumoperitoneum. Sexual history in sex-
ually active women is an important part of
Author Affiliation: School of Nursing and Health
Sciences, Robert Morris University, Moon Township,
the patient’s history, as air can enter the peri-
Pennsylvania. toneum via the vaginal pelvic route during
Medical illustrations by Bethany Barbis, Media Arts Stu- sexual intercourse.
dent, Robert Morris University.
Disclosure: The author reports no conflict of interest.
PHYSICAL EXAMINATION
Corresponding Author: Denise R. Ramponi, DNP,
FNP-C, ENP-BC, FAEN, FAANP, CEN, School of Nursing “Benign pneumoperitoneum” is a term uti-
and Health Sciences, Robert Morris University, Scaife
Hall, 6001 University Blvd, Moon Township, PA 15108 lized when a patient is asymptomatic but has
(dramponi@comcast.net). evidence of free intra-abdominal air. Clinical
DOI: 10.1097/TME.0000000000000189 manifestations of benign pneumoperitoneum

87

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 88 Advanced Emergency Nursing Journal

can include abdominal distention, soft ab- peritonitis, therefore requiring aggressive sur-
domen, but no signs of peritonitis or abdom- gical intervention to remove any intraperi-
inal wall redness. Patients with pneumoperi- toneal barium. Pneumoperitoneum can also
toneum that extends to pneumomediastinum be found on imaging for 7 days after an
often display dyspnea, chest, and neck pain, abdominal surgical procedure, including la-
with subcutaneous emphysema in the cervi- paroscopy, and may last for up to 4 weeks
cal and neck soft tissues. Patients with hol- (Gayer et al., 2000).
low viscus perforation have decreased or no Pneumatic enema is often used for ileo-
bowel sounds, signs of peritonitis, and often cecal intussusception reduction. An adverse
progresses to redness and swelling of the ab- sequela of tension pneumoperitoneum
dominal wall. can occur following this procedure when
Tension pneumoperitoneum occurs in pa- excessive air is insufflated into the rectum
tients when free intra-abdominal gas is un- to reduce the intussusception, causing a
der pressure, compromising blood flow and perforation leading to pneumoperitoneum.
visceral function. This massive accumulation Intraperitoneal or retroperitoneal free air can
of air pressure compresses the inferior vena have respiratory-associated causes such as
cava, resulting in decreased venous return mechanical ventilation-induced barotrauma,
and reduced cardiac output. These patients bronchial asthma, and pneumothorax
often have severe abdominal pain, abdominal through pleural and diaphragmatic defects.
tenderness, and abdominal distension. When Incidence of ventilation-induced pneu-
severe, patients may present with dyspnea, moperitoneum is estimated at 7% (Henry,
venous congestion signs such as skin mot- Ali, Banks, & Dais, 1986). It has also been
tling or edema, and signs of aortic occlusion noted that there is an open access between
such as loss of peripheral pulses in the lower the vagina and the abdomen. Pneumoperi-
extremities. toneum can result from pelvic manipulation
or insufflation, and sexual intercourse. More
than 90% of pneumoperitoneum are caused
CAUSES
by visceral perforation (Duan et al., 2017).
Pneumoperitoneum often results from a per- Perforated viscus can include perforation
foration in the GI tract, such as a ruptured from peptic ulcer, stomach, small intestine, or
hollow viscus. Once the diagnosis of pneu- colon.
moperitoneum is made, a search for the
source is needed. Perforation of the GI tract
BODY COMPARTMENTS
can occur following colonoscopy, barium en-
ema, or percutaneous endoscopic gastros- There are various potential pathways for air
tomy tube placement. Mayo Clinic (Farley movement along the fascial planes of the
et al., 1997) estimated large bowel perforation body from one compartment to the next.
at 0.075% incidence following colonoscopy in The compartments of the body are anatom-
a retrospective study of 57,028 colonoscopy ically connected, allowing air movement via
procedures. Patients at higher risk of perfora- the fascial planes with differences in pres-
tion include those with diverticulosis, rectal sure (see Figure 1). Air can spread from one
disease, cancer, inflammatory bowel disease, compartment to the adjacent compartment
or stricture. Crohn’s disease has an incidence via an opening and a pressure gradient (see
of 1% perforation of the small bowel and is Figure 2). Air can dissect from the medi-
the most common cause of small bowel per- astinum into the soft tissues of the neck, re-
foration in the Western world (Greenstein, sulting in subcutaneous emphysema in the
Mann, Sachar, & Aufses, 1985; Greenstein soft tissues. Air can dissect through the pleu-
et al., 1987). Barium sulfate leakage into the ral space in the chest cavity into the abdomen
peritoneum can cause a progressive lethal with defects in the diaphragm. Air can dissect

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 April–June 2018 r Vol. 40, No. 2 Pneumoperitoneum 89

diaphragm (see Figures 3 and 4). Another

finding of pneumoperitoneum includes air on
both sides of the bowel wall known as Rigler’s
sign (see Figures 5 and 6). Rigler’s sign is also
referred to as the “double-wall sign,” as air is
seen on both the intraluminal and peritoneal
sides of the intestinal wall. Other findings on
plain radiographs can include gas outlining
the falciform ligament and air along the psoas
muscles (Pollard & Entzian, 2005). If the pa-
tient is unable to stand for a KUB radiograph,
a left lateral decubitus radiograph can be uti-
lized, demonstrating free air rising to the sur-
face of the abdomen as the patient is lying on
his or her side.
Figure 1. Compartments or cavities of the body.
Illustration is the original artwork by Bethany
Barbis.

along the perivascular tissue from the medi-

astinum into the abdomen.

RADIOGRAPHIC STUDIES
One of the most common findings of pneu-
moperitoneum on a plain radiograph, such
as kidneys, ureters, and bladder (KUB) film
of pneumoperitoneum, is free air under the

Figure 3. Pneumoperitoneum. Plain radiograph of

the right upper quadrant shows a tiny streak of air
Figure 2. Examples of how air can dissect from under the diaphragm due to a pneumoperitoneum.
one compartment to adjacent compartments via air From Pneumoperitoneum Imaging, by A. N.
pressure gradients to cause pneumoperitoneum. Khan and M. Chandramohan, 2016, Medscape.
Illustration is the original artwork by Bethany Retrieved from https://emedicine.medscape.com/
Barbis. article/372053-overview. Used with permission.

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 90 Advanced Emergency Nursing Journal

Figure 4. Pneumoperitoneum. Upright chest ra- Figure 5. Clear definition of both the inner and
diograph shows a large collection of air under outer walls of the bowel—Rigler’s sign. From
both hemidiaphragms due to perforated duodenal “Acute Onset of Abdominal Pain in a 76-Year-
ulcer. From Pneumoperitoneum Imaging, by A. Old Man,” by G. Dehadrai, 2017, Medscape.
N. Khan and M. Chandramohan, 2016, Medscape. Retrieved from https://reference.medscape.com/
Retrieved from https://emedicine.medscape.com/ viewarticle/727508. Used with permission.
article/372053-overview. Used with permission.
tomography (CT) has a higher sensitivity of
Perforations to retroperitoneal hollow orga- 92% compared with 74% for plain radiography
ns can also cause free air in the retroperitoneal for the presence of free intraperitoneal air
space. Organs in the retroperitoneal space (Catalano, 1996). A CT scan with oral con-
include a portion of the esophagus, the trast provides opacity of the bowel lumen to
duodenum, ascending and descending identify a bowel leak in the GI tract. Perfora-
colon, rectum, and the urinary tract system. tions in the distal small bowel or large bowel
Retroperitoneal infections, such as emphy- can take several hours before the oral contrast
sematous pyelonephritis, can produce gas in opacifies the bowel lumen. This time lapse
the retroperitoneal space, creating a “mottled can be difficult, particularly in a very ill pa-
air sign” demonstrated by a cluster of small tient. A CT scan utilizes radiation and is more
numerous air bubbles on plain abdominal expensive than plain radiographs and ultra-
radiograph (Wang, Wang, Chow, Chiu, & sound scan. Sensitivity of a CT scan has much
Yang, 2004; Yokomuro et al., 2004). Free lower ranges from 33% to 94% in identifying
air in the retroperitoneal space is character- small bowel perforations (Grassi, Pinto, Rossi,
istically seen by a thread like radiolucency & Rotondo, 1998; Scherck, Shatney, Sensaki,
surrounding the perforated organ (Yokomuro & Selivanov, 1994). The small bowel is of-
et al., 2004). ten collapsed; thus, it does not contain much
air or liquid, which makes CT scan diagnosis
of small bowel perforation more difficult. A
COMPUTED TOMOGRAPHY
CT scan with oral contrast has a 100% sen-
Despite plain radiographs often providing the sitivity for perforations of the lower GI tract
diagnosis of pneumoperitoneum, computed including the stomach, duodenum, and colon

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 April–June 2018 r Vol. 40, No. 2 Pneumoperitoneum 91

Figure 7. Pneumoperitoneum. Contrast-enhanced

axial computed tomographic scan through the
liver shows a collection of air anterior to the
liver. Also note the air surrounding the gall-
bladder and the leakage of water-soluble con-
trast material from a perforated duodenal ulcer.
From Pneumoperitoneum Imaging, by A. N.
Khan, and M. Chandramohan, 2016, Medscape.
Figure 6. Clear definition of both the inner wall
Retrieved from https://emedicine.medscape.com/
and outer wall of the bowel (the Rigler sign) and
article/372053-overview. Used with permission.
the presence of free air under the right hemidi-
aphragm demonstrate pneumoperitoneum. From
the investigational method of choice, as gas
“Acute Onset of Abcominal Pain in a 76-Year-Old
Man” by G. Dehadrai, 2017, Medscape. Retrieved is a reflector that does not allow the transmis-
from http://reference.medscape.com/viewarticle/ sion of ultrasound waves. The gas within the
727508. Used with permission. bowel wall also can prevent an accurate in-
terpretation (Goudie, 2013). Ultrasound scan
(Catalano, 1996). A CT scan with oral contrast can identify free intra-abdominal fluid and in-
would demonstrate extravasation of contrast flammatory masses that cannot be seen on
into the abdomen if perforation of the GI tract plain radiographs. The disadvantage of ultra-
exists (see Figures 5 and 6). A CT scan is able sonography is that it is operator dependent.
to differentiate air in the retroperitoneal space Ultrasonography is also quite limited to di-
from other compartments (see Figures 7 agnose pneumoperitoneum in those patients
and 8). who are obese or have large amounts of
intra-abdominal gas (Stanford, McGonigal, &
Weigelt, 1999).
ULTRASONOGRAPHY
Ultrasonography is readily available at most INTERVENTIONS
centers and is commonly used to look for per-
Hospital Admission
forations. It is particularly advantageous in
those patients in whom radiation should be A patient’s clinical examination and diagnos-
avoided such as pregnant patients, pediatric tic findings will guide whether the patient
patients, and patients of childbearing age. It needs surgical management or can be conser-
can be used to diagnose and monitor free air vatively managed. Patients who may be con-
in the abdomen with the advantage of no ra- sidered for conservative treatment include
diation exposure (Nurnberg et al., 2007). Ul- patients with perforations that are asymp-
trasound scan is also less costly to perform tomatic, perforations without extravasation,
than a CT scan. It is generally not considered and those diagnosed within 8 hr of injury with

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 92 Advanced Emergency Nursing Journal

Figure 8. Pneumoperitoneum. Nonenhanced axial computed tomographic scan through the tip of the liver
shows leakage of oral contrast material (arrows) from a perforated gastric ulcer. From Pneumoperitoneum
Imaging, by A. N. Khan and M. Chandramohan, 2016, Medscape. Retrieved from https://emedicine.
medscape.com/article/372053-overview. Used with permission.

mild symptoms (Pollard & Entzian, 2005). sources including laparoscopy, gas-forming
The majority of nonsurgical pneumoperi- bacterial infection, and sexual intercourse.
toneum are caused by mechanical ventilation The patient’s history of conditions such as gas-
(Mularski, Sippel, & Osborne, 2000). These tric or duodenal ulcer, irritable bowel disease,
patients are intubated and often have multiple diverticulitis, or recent surgery can make the
comorbidities, including immunosuppression patient at higher risk for pneumoperitoneum.
and high-dose steroid use. This can lead to Patient symptoms can range from abdominal
peritonitis and sepsis. Those patients should distention with decreased bowel sounds to
be admitted to the hospital, ordered bowel severe abdominal pain, lower extremity mot-
rest, intravenous fluids, intravenous antibi- tling, and loss of pulses. Pneumoperitoneum
otics, and close observation. These patients can be diagnosed on plain KUB or lateral decu-
should be monitored for changes in vital signs, bitus radiographs with the finding of free air
leukocytosis, and return of bowel function in the abdomen. Oral contrast CT scan is the
and resolution of abdominal pain. primary diagnostic tool to determine whether
surgery is necessary. It may take several hours
Surgical Intervention for the contrast to enter the distal small bowel
and large intestine if that is the area of bowel
When CT scan with oral contrast demon-
perforation Mechanical ventilation is the most
strates extravasation of contrast, operative in-
common cause of nonsurgical pneumoperi-
tervention is indicated and surgery should be
toneum. Surgical consult is often necessary as
urgently consulted.
operative intervention is indicated in 85%–
95% of pneumoperitoneum cases (Mularski
CONCLUSION et al., 2000).
Pneumoperitoneum is often caused by a rup-
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