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In pneumoperitoneum, free abdominal air produces a sonographic appearance of linear enhancement of peritoneal stripe with reverberation artifacts (Fig. 1a) and normal air within the lumen of the gastrointestinal tract is recognizable by its association with bowel and moves with peristalsis (Fig. The normal peritoneal stripe is identified by US as a single or double echogenic line posterior to the anterior abdominal wall (Fig. Previous studies evaluated diagnostic performance of abdominal US to detect free intraperitoneal air demonstrating that US has a superior sensitivity to diagnose pneumoperitoneum compared with abdominal radiography with the most important sonographic findings including the enhancement of peritoneal stripe and reverberation with a ring down artifact starting from peritoneum. The use of bedside ultrasonography (US) to diagnose abdominal aneurysm, biliary colic/cholecystitis, hydronephrosis and free intra-abdominal fluid in patients presenting to the ED with abdominal pain is well established. Computed tomography (CT) is considered the вЂњgold standardвЂќ for the recognition of free intraperitoneal air however, is not a cost-effective option as a screening test for patients with acute abdominal pain, exposes to significant radiations, is not always available in every centers and requires patients to be transferred for examination. It is a rare cause of acute abdominal pain representing less than 1В % of presentation to emergency department (ED) and its prompt diagnosis is paramount due to its high mortality.Д¬linical signs and symptoms have low diagnostic accuracy and abdominal radiography is positive in 55вЂ“85В % of cases. Pneumoperitoneum most commonly results from a perforated hollow viscus. US could be a useful bedside screening test for pneumoperitoneum.

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Senior physicians can recognize US signs of pneumoperitoneum with a good accuracy and reliability sensitivity of US could be superior to abdominal radiography and a 2 fast-scan exam seems as accurate as full abdominal examination. Accuracy (68.2В %, 95В % CI 51.4вЂ“80.9В %) of junior reviewers evaluating US was lower than senior reviewers. Inter- and intra-observer agreement (k) were 0.64 and 0.95, respectively. Finally, accuracy of US was compared with abdominal radiography in patients with available images. Furthermore, we compared the accuracy of a вЂњ2 scan-fast examвЂќ (epigastrium and right hypochondrium) vs the full US examination and the accuracy of physicians expert in US vs nonexpert ones. We evaluated accuracy, intra- and inter-observer agreement of abdominal US when reviewed by senior physicians. Abdominal US was performed according to a standardized protocol that included the following scans: epigastrium, right and left hypochondrium, umbilical area and right hypochondrium with the patient lying on the left flank.

Abdominal US videos were obtained from consecutive patients presenting to ED complaining abdominal pain with the diagnosis of pneumoperitoneum established by CT. Four senior and two junior physicians were shown, in an unpaired randomized order, abdominal US videos from 11 patients with and 11 patients without pneumoperitoneum. This was a prospective observational study. The aims of this pilot study were to define the diagnostic performance and the reliability of abdominal US for the diagnosis of pneumoperitoneum.

Ultrasonography (US) can detect free intraperitoneal air however, its accuracy remains unclear. Pneumoperitoneum is a rare cause of abdominal pain characterized by a high mortality.

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