Rigler Sign


Article Author:
Nelson Sanchez Arroyo


Article Editor:
Joshua Solano


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
3/19/2019 5:00:35 PM

Definition/Introduction

The Rigler sign, or double-wall sign, is an indication of free air enclosed within the peritoneal cavity (pneumoperitoneum), imprinting a visible pattern on a plain radiographic image of the abdomen, in supine technique. This sign presents because of the separation between free air and intraluminal by the intestinal wall, marking the air radiolucency and radiopacity of the wall, then both serosal and luminal surfaces of bowel are visible.[1]

American radiologist Leo G. Rigler (1896-1979) in 1942 described this sign of pneumoperitoneum. He described the pattern in four cases report in 1941. He observed this sign was present when large quantities of free air are in the peritoneal cavity.[2] 

Issues of Concern

In upright chest radiography or abdominal radiography, pneumoperitoneum is detectable under special conditions in small quantities as little as 1mL.[3] CT scan has greater sensitivity and specificity than conventional radiographic technique is more available and cheaper.[4] Because a large percentage of patients who require abdominal radiography for suspected pneumoperitoneum are ill and unable to stand or sit, the plain supine projection becomes an option. This modality has lower diagnostic accuracy for pneumoperitoneum (56%) compared with other projections (left lateral decubitus 96%, chest 85%, upright 60%).[5]  Other studies sustain that radiography can detect pneumoperitoneum only in 69% to 89% of cases with visceral perforation.[6][7] Sensitivity and specificity for detection of pneumoperitoneum by abdominal radiography are low compared with CT scan.[8][9] Dissemination of modern CT scan technology has made abdominal radiography less common in most developed health systems, and conventional abdominal radiology is omitted in the workup of most adult patients with acute abdominal pain.[10]

Clinical Significance

Rigler sign is the second most common sign of pneumoperitoneum, the first being the right upper quadrant subdiaphragmatic free air. The incidence of Rigler sign has been reported in study cases with a lesser prevalence then right upper quadrant subdiaphragmatic free air (46% vs. 32%).[11] For its presence, a large quantity of free air must be around 1000mL for clear recognition. Pseudo-Rigler Sign occurs when two loops of gas-distended bowel make contact, enhancing the intestinal wall radiopacity image against the air-filled loops, misleading the diagnosis of pneumoperitoneum.[12] If Rigler sign is believed to be present, then abdomen/pelvis CT scanning and surgical consultation are warranted in the proper clinical context.[10]


  • Image 8757 Not availableImage 8757 Not available
    Contributed by Joshua Solano, MD
Attributed To: Contributed by Joshua Solano, MD

Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Rigler Sign - Questions

Take a quiz of the questions on this article.

Take Quiz
The radiologist reports a positive Rigler sign (double wall sign) on an abdominal radiograph. The patient may have what abdominal condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Rigler Sign - References

References

Ly JQ, The Rigler sign. Radiology. 2003 Sep;     [PubMed]
Lewicki AM, The Rigler sign and Leo G. Rigler. Radiology. 2004 Oct;     [PubMed]
Gans SL,Stoker J,Boermeester MA, Plain abdominal radiography in acute abdominal pain; past, present, and future. International journal of general medicine. 2012;     [PubMed]
Stapakis JC,Thickman D, Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. Journal of computer assisted tomography. 1992 Sep-Oct;     [PubMed]
Roh JJ,Thompson JS,Harned RK,Hodgson PE, Value of pneumoperitoneum in the diagnosis of visceral perforation. American journal of surgery. 1983 Dec;     [PubMed]
Winek TG,Mosely HS,Grout G,Luallin D, Pneumoperitoneum and its association with ruptured abdominal viscus. Archives of surgery (Chicago, Ill. : 1960). 1988 Jun;     [PubMed]
Bansal J,Jenaw RK,Rao J,Kankaria J,Agrawal NN, Effectiveness of plain radiography in diagnosing hollow viscus perforation: study of 1,723 patients of perforation peritonitis. Emergency radiology. 2012 Apr;     [PubMed]
Catalano O, [Computed tomography in the study of gastrointestinal perforation]. La Radiologia medica. 1996 Mar;     [PubMed]
Laméris W,van Randen A,van Es HW,van Heesewijk JP,van Ramshorst B,Bouma WH,ten Hove W,van Leeuwen MS,van Keulen EM,Dijkgraaf MG,Bossuyt PM,Boermeester MA,Stoker J, Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ (Clinical research ed.). 2009 Jun 26;     [PubMed]
Levine MS,Scheiner JD,Rubesin SE,Laufer I,Herlinger H, Diagnosis of pneumoperitoneum on supine abdominal radiographs. AJR. American journal of roentgenology. 1991 Apr;     [PubMed]
de Lacey G,Bloomberg T,Wignall BK, Pneumoperitoneum: the misleading double wall sign. Clinical radiology. 1977 Jul;     [PubMed]
Gans SL,Pols MA,Stoker J,Boermeester MA, Guideline for the diagnostic pathway in patients with acute abdominal pain. Digestive surgery. 2015     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-General. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-General, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-General, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-General. When it is time for the Surgery-General board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-General.