On a radiograph you need the right film and enough time upright; on CT you need a lung window, and that is where small volumes live.
Orient first
- Free gas rises. On an ERECT film it collects under the diaphragm; on a LEFT LATERAL DECUBITUS it collects over the liver, away from the gastric bubble.
- The patient must be upright or decubitus for AT LEAST 5–10 minutes for gas to migrate. A film taken immediately after sitting up can be falsely negative — this is the commonest technical cause of a missed perforation.
- A supine film is the worst study for free gas, and most ward films are supine. Know the supine signs, because that may be all you get.
- On CT, free gas is obvious on a LUNG WINDOW and easy to miss on a soft-tissue window. Always re-window.
Acquire the study
- RADIOGRAPH: erect chest (not abdomen) is the most sensitive film — it includes both hemidiaphragms with the patient upright. If the patient cannot sit, do a LEFT lateral decubitus, left side down, after 10 minutes.
- CT: any phase will show gas. Review the whole abdomen on a LUNG WINDOW deliberately as a separate pass.
- On CT, look at the non-dependent surfaces with the patient supine: anterior to the liver, and in the anterior abdominal wall recesses.
The manoeuvre
- On an erect film, look for a lucent crescent beneath either hemidiaphragm, with a visible thin diaphragm above it.
- Distinguish it from Chilaiditi interposition of colon — look for haustra inside the lucency.
- On a supine film, know the indirect signs: Rigler sign (both sides of the bowel wall visible), the football sign, the falciform ligament sign, triangular gas in the recesses, the doubled-wall appearance.
- On CT, do a dedicated LUNG-WINDOW pass over the whole abdomen.
- Locate the gas and use its distribution to suggest the source: perigastric or perihepatic gas with wall thickening suggests a peptic perforation; pericolic gas with diverticula suggests a colonic one.
- Look for the wall defect itself, focal wall thickening, adjacent fat stranding and any collection.
- Note whether gas is intraperitoneal, retroperitoneal or in the bowel wall — they mean different things.
What confirms it
- Gas outside the bowel lumen, in a non-dependent position, on either an erect/decubitus radiograph or a lung-window CT.
What licenses you to exclude it
- ⚠️ A supine film does not exclude free gas, and a hurriedly taken erect film may not either. State the technique and the time upright, or say the study is not adequate to exclude it.
- A properly-windowed CT is a genuine exclusion.
- Remember that post-operative free gas is expected and can persist for days — correlate with the date of surgery before calling a perforation.
The classic misread
- Reporting "no free gas" on a supine abdominal film.
- Missing small-volume gas because a lung window was never used on CT.
- Mistaking Chilaiditi interposed colon for free gas.
- Calling a perforation on expected post-operative gas.