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Case history
A 3-day-old premature neonate presented with significant abdominal distension. The patient had a history of a difficult intubation for respiratory distress a few hours prior to this presentation. On clinical examination, the abdomen was significantly distended with absent bowel sounds. A portable supine abdominal radiograph demonstrated the Rigler’s and football signs in keeping with a pneumoperitoneum (Fig. 1a). This was confirmed on a lateral decubitus view (Fig. 1b). At surgery, an iatrogenic gastric perforation was repaired.
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a
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b
Fig. 1. (a) Supine abdominal radiograph demonstrating Rigler’s sign (closed arrows) and the football sign (arrow heads) in a patient with iatrogenic gastric perforation. Rigler’s sign is the visualisation of the inner and outer bowel wall owing to pneumoperitoneum, also known as the double-wall sign. The football sign is described as an oval radiolucency owing to pneumoperitoneum that resembles an American football. The vertical opacity of the falciform ligament (open arrow) represents the laces, and the remaining abdomen represents the reaming portion of an American football. (b) The lateral decubitus view confirms the pneumoperitoneum. Note Rigler’s sign (closed arrow).
Signs of pneumoperitoneum
Rigler’s sign was first described in 1941 by L G Rigler as a new radiological sign for recognising free air in the peritoneal cavity on supine radiograph.1 Normally, the mucosal surface of the bowel wall is seen as it is lined by intraluminal gas. The serosal surface of the bowel wall is surrounded by abdominal tissue and not delineated.2 The presence of pneumoperitoneum allows free intra-peritoneal air to be contrasted with intraluminal gas, accentuating the wall of gas-containing viscera.3 Both the inner and outer bowel wall are therefore visible; therefore, it is also known as the double-wall sign.2 It is observed...