Inverted V Sign

The inverted V sign refers to visualization of the medial umbilical folds (they are also known as umbilical ligaments, but folds are the preferred term), which together form an inverted V-shaped increased density in the pelvis outlined by free air24,25 (Fig. 7-11). Anatomically, there are actually two pairs of folds in the lower abdominal wall that can create an inverted V; the medial umbilical folds representing the obliterated umbilical arteries, and the lateral umbilical folds containing the inferior epigastric vessels.22

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Falciform Ligament Anterior Wall

Fig. 7—1. Falciform ligament and ligamentum teres.

The gross specimen of the upper abdominal contents demonstrates the falciform ligament with its attachment to the resected anterior abdominal wall (arrowheads) and the ligamentum teres (arrows) lying along the free margin of the sickle-shaped fold of the peritoneum, the falciform ligament. Note also the hepatic attachment of the falciform ligament. (From Gosling JA, Harris PF, Humpherson JR: Human Anatomy: Text and Colour Atlas. Brower Medical, London, 1990, pp 4-28.)

Pneumoperitoneum Falciform Ligament

Fig. 7—2. Falciform ligament.

(a) A thin vertical paramedian line represents the falciform ligament (curved arrow) delineated by free air on both sides.

(b) CT reveals the falciform ligament (curved arrow) and a gas-distended colonic loop (straight arrow) within the anterior peritoneal cavity surrounded by a large pneumoperitoneum.

Fig. 7—2. Falciform ligament.

(a) A thin vertical paramedian line represents the falciform ligament (curved arrow) delineated by free air on both sides.

(b) CT reveals the falciform ligament (curved arrow) and a gas-distended colonic loop (straight arrow) within the anterior peritoneal cavity surrounded by a large pneumoperitoneum.

Inverted Sign Neonate

Fig. 7—3. Falciform ligament.

A slightly rotated supine film shows a large pneumoperitoneum delineating a long falciform ligament (open arrows), thin in its superior aspect but much thicker distally. Note also the ligamentum teres (curved arrow) directed obliquely toward the liver. Rigler's sign is also present.

Rigler Sign Falciform Ligament Sign Pneumoperitoneum

Fig. 7—4. Falciform ligament.

(a) A coronal reformatted image of the anterior abdomen from a CT scan reveals a large pneumo-peritoneum outlining the falciform ligament in the right upper quadrant. The amorphous rounded structure caudal to the ligament represents adhesive bands extending between the anterior abdominal wall and the underlying abdominal contents within the anterior peritoneal cavity, also delineated by free air.

(b) A digital radiograph in cross-table lateral projection demonstrates the falciform ligament as a broad fold of peritoneum (asterisks) and multiple adhesive bands (arrowheads) caudally within the anterior peritoneal cavity surrounded by free air. Diaphragm muscle slips are also delineated (arrow).

Fig. 7—5. Falciform ligament.

An unusually thick falciform ligament (asterisk) having a bulbous lower end is outlined by free air. Note also the hepatic edge seen as a smooth, oblique interface

(arrowheads).

Inverted Sign Free Air

Fig. 7—6. Ligamentum teres, falciform ligament, and hepatic notch.

A supine film during an upper GI series demonstrates juxtaposition of the ligamentum teres (arrows), the falciform ligament (arrowheads), and the ligamentum teres notch (curved arrow). The ligamentum teres is seen as a long curved interface entering the liver. Note also the nodular thickening of the falciform ligament near the umbilicus (asterisk).

(From Cho and Baker.13)

Fig. 7—7. Ligamentum teres sign.

A slightly rotated supine film during a water soluble contrast study of the bowel reveals the extrahepatic ligamentum teres presenting as a thick oblique band of soft tissue density (long arrows). It joins the vertically oriented, thin linear falciform ligament (arrowheads) caudally. The ligamentum teres notch is denoted by the open curved arrow. Small arrows highlight the hepatic attachment of the triangular "anatomic" falciform ligament stretching between the anterior abdominal wall and its free inferior edge, the ligamentum teres. Contrast fills the esophagus. (From Cho and Baker.13)

Fig. 7—5. Falciform ligament.

An unusually thick falciform ligament (asterisk) having a bulbous lower end is outlined by free air. Note also the hepatic edge seen as a smooth, oblique interface

(arrowheads).

Doge Cap Sign Radiology

Fig. 7—8. Morison's pouch air (doges's cap sign.)

A digital radiograph shows air trapped in Morison's pouch posteriorly below the 11th rib (arrow) and air overlying the liver anteriorly, which has a more diffuse presentation. The hepatic attachment of the falciform ligament is also visualized as an oblique curvilinear interface overlying the 10 th rib (arrowheads). (From Cho.16)

Right Left Triangular Ligaments Liver

Fig. 7-9. Illustration of the anterior surface of the liver.

Note the spatial relationship between the ligamentum teres, the falciform ligament, the coronary ligament, and the left triangular ligament with their attachments to the liver.

(From Cho and Baker.14)

Fig. 7-9. Illustration of the anterior surface of the liver.

Note the spatial relationship between the ligamentum teres, the falciform ligament, the coronary ligament, and the left triangular ligament with their attachments to the liver.

(From Cho and Baker.14)

Ligamentum Teres Liver

Fig. 7—10. Ligamentum teres sign.

(a) A supine digital radiograph shows a distinct oblique interface (arrow) representing the extrahepatic segment of the ligamentum teres visualized by adjacent free air.

(b) A corresponding CT image shows a ventral collection of free air outlining the ligamentum teres (open arrow). The black arrow points to the ligamentum teres notch between the medial and lateral segments of the left hepatic lobe.

(From Cho and Baker.13)

Fig. 7—10. Ligamentum teres sign.

(a) A supine digital radiograph shows a distinct oblique interface (arrow) representing the extrahepatic segment of the ligamentum teres visualized by adjacent free air.

(b) A corresponding CT image shows a ventral collection of free air outlining the ligamentum teres (open arrow). The black arrow points to the ligamentum teres notch between the medial and lateral segments of the left hepatic lobe.

(From Cho and Baker.13)

Inverted Sign Pneumoperitoneum

Fig. 7-11. Inverted V sign in an infant with massive pneumoperitoneum from child abuse.

(a) On a digital scout radiograph at the time of CT scan, an inverted V (arrowheads) representing the medial umbilical folds is seen with its apex at the umbilicus. A femoral venous catheter is seen laterally (arrow).

(b) Three CT images with the most superior, at the level of the umbilicus (u) and the other two more caudad, show the medial umbilical folds (arrowheads) outlined by free air converging into the umbilicus.

Fig. 7-11. Inverted V sign in an infant with massive pneumoperitoneum from child abuse.

(a) On a digital scout radiograph at the time of CT scan, an inverted V (arrowheads) representing the medial umbilical folds is seen with its apex at the umbilicus. A femoral venous catheter is seen laterally (arrow).

(b) Three CT images with the most superior, at the level of the umbilicus (u) and the other two more caudad, show the medial umbilical folds (arrowheads) outlined by free air converging into the umbilicus.

Inverted Sign Lateral Umbilical

The urachus is seen as an elongated density slightly wider infe-riorly situated between the umbilicus and the bladder visualized by virtue of free air (arrows). Calcifications in a uterine fibroid are incidentally evident. (From Cho and Baker.17)

The urachus is seen as an elongated density slightly wider infe-riorly situated between the umbilicus and the bladder visualized by virtue of free air (arrows). Calcifications in a uterine fibroid are incidentally evident. (From Cho and Baker.17)

There has been some confusion in the literature regarding the nomenclature of the umbilical ligaments and with respect to the inverted V sign. In older texts and in the original article describing this sign,24 the medial umbilical ligament was erroneously labeled as the lateral umbilical ligament. Moreover, Bray25 in 1984 reported that the inverted V represented the medial umbilical ligaments (obliterated umbilical arteries) in infants and the lateral umbilical ligaments (inferior epigastric arteries) in adults. Some investigators, however, believe that even in adults the medial umbilical ligaments are usually responsible for this sign because they are the more prominent fold pair.5,26 Nonetheless, the inverted V sign requires a large pneumoperitoneum and is never the sole indicator of free air. The sign is often subtle, and only one fold or even only part of one may be visible.

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