WHEN the diagnosis of pneumoperitoneum is suspected from the clinical information in the case of a neonate, it is generally a simple matter to confirm the diagnosis roentgenographically. Filming is performed in either upright, lateral, or left lateral decubitus positions. When a perforation is of such severity that massive amounts of gastric or intestinal air enter the peritoneal cavity, a supine roentgenogram demonstrates the "football sign," which consists of an oval lucency demarcating the peritoneum with visualization of the falciform ligament (Fig 1).1 With pneumoperitoneum, the physical findings that would normally alert the neonatologist to this diagnosis are occasionally not apparent, and an abdominal x-ray film taken with the patient in a recumbent position does not show the football sign. We have found that a homogeneous lucency or streak-like lucencies seen over the liver provide easy recognition of intraperitoneal air, and an appropriate left lateral decubitus or lateral roentgenogram
Wind ES, Pillari GP, Lee WJ. Lucent Liver in the Newborn: A Roentgenographic Sign of Pneumoperitoneum. JAMA. 1977;237(20):2218–2219. doi:10.1001/jama.1977.03270470054026
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