Introduction: Pneumoperitoneum is a radiologic term denoting an abnormal collection of air in the peritoneal cavity. It reflects visceral perforation. Pneumoperitoneum without visceral perforation evidence after laparotomy is called spontaneous or idiopathic pneumoperitoneum. Case Report: We report a case of massive idiopathic pneumoperitoneum in a 3-day-old newborn. Unprepared abdominal x-ray revealed a massive pneumoperitoneum huge oval radiolucency delineated by the parietal peritoneum of the abdominal wall “football sign”, with the visible falciform ligament outlined by air. Emergent laparotomy has found no perforated organs. Recovery was uncomplicated; he received parenteral nutrition for 6 days, and enteral feeding commenced on day 7 postoperatively. Recognizing radiographic patterns that suggest pneumoperitoneum on supine plain radiographs could expedite the diagnostic process and surgical intervention.
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