Spot Diagnosis
Rigler's Sign

Figure 1. Supine radiograph of the abdomen showing the presence of air on both sides of the bowel wall (blue arrows) and infra-diaphragmatic air (white arrows)


Catarina Santiago Gonçalves1, Dora Fontes2, Vasco Herédia3, Maria José Mendes2

Keywords : Rigler's sign, pneumoperitoneum, radiograph

Question :
A male infant born at 31 weeks and 6 days of gestation by vaginal delivery with a birth weight of 1785g had Apgar score of 8 and 9 at 1 and 5 minutes, respectively. The mother’s routine prenatal evaluation was unremarkable and she had completed a course of corticosteroid therapy. The infant needed oxygen supplementation and was started on empirical antibiotics with intravenous (IV) Ampicillin and gentamicin. Minimal enteral nutrition with breast milk was started from second day of life which was gradually increased. On day 6 of life, he needed nasal continuous positive airway pressure due to nosocomial sepsis. Antibiotics were changed to IV Vancomycin and cefotaxime; feeding was stopped, and umbilical line was removed. Two days later, he had further clinical worsening with abdominal distension and decreased bowel sounds. Laboratory studies showed increased inflammatory markers (C reactive protein 24.9mg/dL) with leucopenia (white cell count 4000/cumm). Chest and abdominal radiographs revealed signs of pneumoperitoneum, including Rigler’s sign (Figure 1). An exploratory laparotomy revealed a perforation and necrosis of the cecum, ascending and transverse colon.

What is Rigler's sign?
 
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