Case 17. Diagnosis
==================


## High grade small-bowel obstruction with **massive pneumoperitoneum**

The signs of a pneumoperitoneum that have been described on supine plain films (Fig. 1) include Rigler’s sign (visualization of both sides of the intestinal wall [Fig. 1, arrows]).

![FIG. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/40/5/340/F1.medium.gif)

[FIG. 1](http://canjsurg.ca/content/40/5/340/F1)

FIG. 1 

Occasionally, patients are too sick or injured to stand or to be turned on their side, and supine radiography may be the only option for plain film examination. Levine and associates1 reported that the signs of a pneumoperitoneum are present in 59% of supine abdominal films and the most commonly seen sign is Rigler’s sign.

The bowel wall is outlined very clearly as if etched by a pencil because the gas in the peritoneal space outlines the outside wall. Normally only the inside of the bowel wall can be seen as shown in a plain film (Fig. 2) obtained a few months earlier on this same patient.

![FIG. 2](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/40/5/340/F2.medium.gif)

[FIG. 2](http://canjsurg.ca/content/40/5/340/F2)

FIG. 2 

## Reference

1.  Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol 1991;156:731–2.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.2214/ajr.156.4.2003436&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=2003436&link_type=MED&atom=%2Fcjs%2F40%2F5%2F340.atom) 
    
    [Web of Science](http://canjsurg.ca/lookup/external-ref?access_num=A1991FC83000011&link_type=ISI)