Pneumoperitoneum (Rigler sign) with portal venous and intramural gas from bowel ischemia

Case contributed by RMH Core Conditions


abdo pain

Patient Data

Age: 79
Gender: Male

Free intraperitoneal gas is widespread with moderate dilatation of small bowel in particular and there may also be intramural gas. Rigler sign is present in the left upper quadrant. 

Subtotal colectomy and right iliac fossa ileostomy demonstrated.

There is free intraperitoneal gas and demonstrated mural gas, which is widespread. Diffuse hypoenhancement of the bowel wall. The duodenum is thick walled and demonstrates prominent mural enhancement. Extensive portal venous gas remains present. The ascites has resolved. 

Multiple bilateral peripheral wedge-shaped hypodensities are demonstrated within both kidneys. Within hepatic segment 4B, a para-falciform region of low attenuation most likely represents focal fatty infiltration. Cholelithiasis.


Diffuse bowel hypoenhancement and mural gas, consistent with infarction, as well as free intraperitoneal gas, consistent with perforation. Bilateral wedge-shaped renal hypodensities are highly suspicious for infarcts.

Case Discussion

Key learning points:

  • Rigler sign is an uncommon but unmissable sign on abdominal x-ray for pneumoperitoneum
  • intramural and portal venous gas is considered a pre-mortem sign in bowel ischemia
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Case information

rID: 31041
Published: 18th Sep 2014
Last edited: 20th Dec 2019
Inclusion in quiz mode: Included

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