Gastric Perforation

  • Etiology: placement of a nasogastric tube, placement of a gastrostomy or gastrojejunostomy tube, use of indomethacin to close a patent ductus arteriosus
  • AXR left lateral decubitus: air above the liver (air between abdominal wall and liver)
  • AXR cross-table lateral: for small amounts of free air see tell-tale triangle sign of air between bowel loops, for large amounts of free air see air superiorly between abdominal wall and viscera
  • AXR supine: overall increased lucency of abdomen, American football sign of falciform ligament, inverted Y of umbilical artery ligaments, Rigler’s sign (see air outlining both sides of bowel wall)
  • Note: a nasogastric tube tip that projects over the pelvis should be suspected of not being in the stomach
  • Note: in inflamed abdomen (due to perforation), pneumoperitoneum may be loculated and not be classically seen on upright / decubitus / cross-table lateral views, may appear as fixed air collection that does not appear to conform to bowel

Cases of Gastric Perforation

AXR of gastric perforation from nasogastric tube placement
Supine AXR (left) shows a large amount of air within the abdomen and air outlining both sides of bowel wall (Rigler’s sign) in the right lower quadrant. Supine AXR taken later after pulling back of the nasogastric tube out of the stomach shows visualization of the falciform ligament over the spine (American football sign)
AXR of gastric perforation from nasogastric tube placement
Supine AXR (above) shows increased lucency throughout the central abdomen and left lateral decubitus AXR (below) shows air between the abdominal wall and the liver. On both views the tip of the nasogastric tube projects inferior to the gas-filled stomach.
AXR of gastric perforation from nasogastric tube placement
Supine and left lateral decubitus AXR (left) show a nasogastric tube with its tip deep in the pelvis without evidence of free air. Supine AXR taken after pulling the nasogastric tube back into the stomach (above right) shows increased lucency throughout the central abdomen and left lateral decubitus AXR taken at same time (below right) shows air between the abdominal wall and the liver.