- Email: [email protected]
Rigler sign: an underappreciated alert for pneumoperitoneum
The American Journal of Surgery (2008) 196, e5– e6
Clinical Image
Rigler sign: an underappreciated alert for pneumoperitoneum Haridimos Markogiannakis, M.D.*, Klio Fili, M.D., Ph.D., Konstantinos Spaniolas, M.D., Vasiliki Bizimi, M.D., Vasiliki Katsiva, M.D., Dimitrios Theodorou, M.D., Ph.D. 1st Department of Propaedeutic Surgery, Hippokrateion Hospital, Athens Medical School, University of Athens, Athens, Greece
KEYWORDS: Rigler sign; Supine abdominal radiograph; Pneumoperitoneum
Abstract. A patient presented with abdominal pain. Supine abdominal radiograph disclosed free intraperitoneal air (Rigler sign). This finding prompted further work-up and treatment. © 2008 Elsevier Inc. All rights reserved.
A 73-year-old malnourished woman with an unremarkable medical history presented with abdominal pain of 6 hours’ duration. Clinical examination was normal apart from abdominal distension. Routine laboratory tests revealed mild leukocytosis. Because the patient was unable to achieve an upright position owing to weakness and abdominal pain, supine chest and abdominal radiographs were performed. The chest radiograph was normal whereas the abdominal radiograph showed distended bowel loops and double delineation of the bowel wall (Rigler sign) (Fig. 1), indicating pneumoperitoneum. The patient underwent a computerized tomography (CT) scan of the abdomen, confirming the presence of free intraperitoneal air (Fig. 2). Urgent laparotomy revealed a perforated gastric ulcer. When a perforated abdominal viscus is suspected, an erect chest radiograph or decubitus abdominal radiograph is useful even though plain radiographs are less sensitive and specific than CT.1–3 In the emergency department setting, however, patients often are unable to achieve an upright or decubitus position. Abdominal CT, however, should be * Corresponding author. Tel.: ⫹30-6976788806; fax: ⫹30-2107707574. E-mail address: [email protected] Manuscript received January 23, 2007; revised manuscript July 19, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.07.030
Figure 1 Abdominal supine radiograph showing air in both sides of the bowel wall (Rigler sign) (white arrows). Both sides of the bowel wall are visualized; the wall appears as a white linear stripe.
e6
The American Journal of Surgery, Vol 196, No 3, September 2008 pneumoperitoneum on a supine abdominal film is visualization of both the serosal and the luminal surfaces of bowel. This is known as the Rigler sign, or the double-wall sign, and was described by Rigler4 in 1941. Despite its significance, it has been mentioned only in few reports, possibly because it often is overlooked.5–7
References
Figure 2
Abdominal CT scan revealing free intraperitoneal air.
avoided in hemodynamically unstable patients. Therefore, a supine abdominal radiograph may be the only option. A sign of pneumoperitoneum on supine abdominal films is the visualization of both sides of the bowel wall, the serosal and the luminal surface, which appears as a white linear stripe. Gas normally outlines only the luminal surface of the bowel wall and not the serosal surface. A sign of
1. Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983;146:830 –3. 2. Rozycki GS, Tremblay L, Feliciano DV, et al. Three hundred consecutive emergent celiotomies in general surgery patients: influence of advanced diagnostic imaging techniques and procedures on diagnosis. Ann Surg 2002;235:681–9. 3. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713– 6. 4. Rigler LG. Spontaneous pneumoperitoneum: a roentgenologic sign found in the supine position. Radiology 1941;37:604 –7. 5. Levine MS, Scheiner JD, Rubesin SE, et al. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol 1991; 156:731–5. 6. Ly JQ. The Rigler sign. Radiology 2003;228:706 –7. 7. Lewicki AM. The Rigler sign and LG Rigler. Radiology 2004;233: 7–12.
Clinical Image
Rigler sign: an underappreciated alert for pneumoperitoneum Haridimos Markogiannakis, M.D.*, Klio Fili, M.D., Ph.D., Konstantinos Spaniolas, M.D., Vasiliki Bizimi, M.D., Vasiliki Katsiva, M.D., Dimitrios Theodorou, M.D., Ph.D. 1st Department of Propaedeutic Surgery, Hippokrateion Hospital, Athens Medical School, University of Athens, Athens, Greece
KEYWORDS: Rigler sign; Supine abdominal radiograph; Pneumoperitoneum
Abstract. A patient presented with abdominal pain. Supine abdominal radiograph disclosed free intraperitoneal air (Rigler sign). This finding prompted further work-up and treatment. © 2008 Elsevier Inc. All rights reserved.
A 73-year-old malnourished woman with an unremarkable medical history presented with abdominal pain of 6 hours’ duration. Clinical examination was normal apart from abdominal distension. Routine laboratory tests revealed mild leukocytosis. Because the patient was unable to achieve an upright position owing to weakness and abdominal pain, supine chest and abdominal radiographs were performed. The chest radiograph was normal whereas the abdominal radiograph showed distended bowel loops and double delineation of the bowel wall (Rigler sign) (Fig. 1), indicating pneumoperitoneum. The patient underwent a computerized tomography (CT) scan of the abdomen, confirming the presence of free intraperitoneal air (Fig. 2). Urgent laparotomy revealed a perforated gastric ulcer. When a perforated abdominal viscus is suspected, an erect chest radiograph or decubitus abdominal radiograph is useful even though plain radiographs are less sensitive and specific than CT.1–3 In the emergency department setting, however, patients often are unable to achieve an upright or decubitus position. Abdominal CT, however, should be * Corresponding author. Tel.: ⫹30-6976788806; fax: ⫹30-2107707574. E-mail address: [email protected] Manuscript received January 23, 2007; revised manuscript July 19, 2007
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.07.030
Figure 1 Abdominal supine radiograph showing air in both sides of the bowel wall (Rigler sign) (white arrows). Both sides of the bowel wall are visualized; the wall appears as a white linear stripe.
e6
The American Journal of Surgery, Vol 196, No 3, September 2008 pneumoperitoneum on a supine abdominal film is visualization of both the serosal and the luminal surfaces of bowel. This is known as the Rigler sign, or the double-wall sign, and was described by Rigler4 in 1941. Despite its significance, it has been mentioned only in few reports, possibly because it often is overlooked.5–7
References
Figure 2
Abdominal CT scan revealing free intraperitoneal air.
avoided in hemodynamically unstable patients. Therefore, a supine abdominal radiograph may be the only option. A sign of pneumoperitoneum on supine abdominal films is the visualization of both sides of the bowel wall, the serosal and the luminal surface, which appears as a white linear stripe. Gas normally outlines only the luminal surface of the bowel wall and not the serosal surface. A sign of
1. Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983;146:830 –3. 2. Rozycki GS, Tremblay L, Feliciano DV, et al. Three hundred consecutive emergent celiotomies in general surgery patients: influence of advanced diagnostic imaging techniques and procedures on diagnosis. Ann Surg 2002;235:681–9. 3. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713– 6. 4. Rigler LG. Spontaneous pneumoperitoneum: a roentgenologic sign found in the supine position. Radiology 1941;37:604 –7. 5. Levine MS, Scheiner JD, Rubesin SE, et al. Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR Am J Roentgenol 1991; 156:731–5. 6. Ly JQ. The Rigler sign. Radiology 2003;228:706 –7. 7. Lewicki AM. The Rigler sign and LG Rigler. Radiology 2004;233: 7–12.