An unusual presentation of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess: Report of a case

We describe a rare case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess in a 59-year-old man. The patient was diagnosed as having a hollow viscus perforation based on a sudden onset of acute abdominal pain along with radiological evidence of bilateral subphrenic feee air (pneumoperitoneum), and underwent an emergency laparotomy. Contrary to expectations, the surgery revealed no perforations of the hollow viscus, but instead a ruptured liver abscess at the dome of the right hepatic lobe was identified associated with suppurative peritonitis. To the best of our knowledge, such a case of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing liver abscess is extremely rare.     

Ruptured liver abscess presenting as pneumoperitoneum

The presence of free air within the peritoneal cavity, referred to as pneumoperitoneum, in 85% to 90% of cases is due to perforated bowel. The rare case is reported of pneumoperitoneum resulting from a ruptured liver abscess in a young male with no comorbidity.A ruptured pyogenic left lobe liver abscess in a 23-year-old male was accompanied by chest X-ray features suggestive of free gas under the diaphragm with peritonitis. Exploratory laparotomy was performed, with localization and drainage of the liver abscess and thorough peritoneal lavage. Culture of the pus from the liver abscess grew Klebsiella sensitive to Piperacillin and Tazobactam, and antibiotic treatment was administere Conclusion: Although pneumoperitoneum resulting from a ruptured liver abscess is rare, it must be kept in mind as a possible source, especially when the hollow organs are normal.     

Conservative management of idiopathic pneumoperitoneum masquerading as peritonitis: Report of a case

Pneumoperitoneum is most commonly caused by the perforation of a hollow viscus, in which case an emergency laparotomy is indicated. We report herein the case of a patient who, presented with the signs and symptoms of peritonitis, but who was found to have idiopathic pneumoperitoneum which was successfully managed by conservative treatment. A 70-year-old man presented with epigastric pain, nausea, and a severely distended and tympanitic abdomen. Abdominal examination revealed diffuse tenderness with guarding, but no rebound tenderness. He was febrile with leukocytosis and high C-reactive protein. Chest X-ray and abdominal computed tomography demonstrated a massive pneumoperitoneum without pneumothorax, pneumomediastinum, pneumortroperitoneum, or subcutaneous emphysema, and subsequent examinations failed to demonstrate perforation of a hollow viscus. Thus, a diagnosis of idiopathic pneumoperitoneum was made, and the patient was managed conservatively, which resulted in a successful outcome. This experience and a review of the literature suggest that idiopathic pneumoperitoneum is amenable to conservative management, even when the signs and symptoms of peritonitis are present.     

Jejunal gastric heterotopia presenting as perforation peritonitis in a middle-aged adult: A case report

IntroductionGastric heterotopia rarely occurs in the small intestine beyond ligament of Treitz. Most cases of jejunal gastric heterotopia have been reported in children and young adults. Herein we report a case of jejunal gastric heterotopia presenting as a perforation peritonitis in a middle-aged adult.Presentation of caseA 51-year-old male presented with abrupt onset abdominal pain of 1 day duration. Physical examination revealed abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography revealed pneumoperitoneum, suggestive of hollow viscus perforation. At emergency laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. On macroscopic examination, the mucosa contained a 3 × 4 cm ill-defined, shallow ulceration next to the perforation site. Microscopically, the mucosa surrounding the perforation site revealed gastric heterotopia which consisted of gastric foveolar epithelium along with abundant pyloric glands and a few fundic glands.DiscussionTo the best of our knowledge, this case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.ConclusionJejunal gastric heterotopia should also be considered in the differential diagnosis of perforation peritonitis in adults.     

Spontaneous pneumoperitoneum. A surgical dilemma

Pneumoperitoneum is usually the result of hollow viscus perforation with associated peritonitis. Nonsurgical spontaneous pneumoperitoneum incidental to intrathoracic, intra-abdominal, gynecologic, iatrogenic, and other miscellaneous causes not associated with perforated viscus have been documented in the literature. Seven cases of spontaneous pneumoperitoneum admitted over 3-year period to Grady Memorial Hospital, Atlanta, Georgia are reported. Six patients with pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in any of these patients. A seventh patient, on ventilatory support, was managed conservatively after performing a diagnostic peritoneal lavage that was negative. There were no cases of radiographically misdiagnosed pneumoperitoneum. Pneumoperitoneum, preceded by a reasonable incidental cause in a patient with a adequate abdominal examination, may warrant continued observation thus avoiding an unnecessary laparotomy.     

Spontaneous pneumoperitoneum associated with colonic pseudo-obstruction

Pneumoperitoneum is almost always pathognomonic of a perforated abdominal viscus requiring urgent surgical intervention. Spontaneous or non-surgical pneumoperitoneum is a rare clinical condition arising secondary to abdominal, thoracic, gynaecologic or idiopathic causes. In addition to good clinical judgement, an important component in the management process is to rule out other causes of pneumoperitoneum by performing appropriate investigations. We describe a 60-year-old man who presented with clinical features of pseudo-obstruction, following an injury to his back which was compounded by hypokalaemia. Roentgenography revealed massive pneumoperitoneum and colonic distension. As there were no overt clinical features of peritonitis, the patient was managed conservatively with parenteral nutrition and close observation. A water-soluble contrast enema and computed tomography of the abdomen were of no help in identifying the cause of his pneumoperitoneum but were helpful in eliminating the presence of hollow viscus perforation or an obvious inflammatory focus. The aetiology of pneumoperitoneum in our patient was most likely due to dissection of air through the distended colonic wall, secondary to large bowel pseudo-obstruction. The diagnosis of spontaneous or non-surgical pneumoperitoneum is one of exclusion and we stress the importance of relying on clinical parameters when managing such patients conservatively.     

Spontaneous Pneumoperitoneum Associated with Colonic Pseudo-Obstruction

Pneumoperitoneum is almost always pathognomonic of a perforated abdominal viscus requiring urgent surgical intervention. Spontaneous or non-surgical pneumoperitoneum is a rare clinical condition arising secondary to abdominal, thoracic, gynaecologic or idiopathic causes. In addition to good clinical judgement, an important component in the management process is to rule out other causes of pneumoperitoneum by performing appropriate investigations. We describe a 60-year-old man who presented with clinical features of pseudo-obstruction, following an injury to his back which was compounded by hypokalaemia. Roentgenography revealed massive pneumoperitoneum and colonic distension. As there were no overt clinical features of peritonitis, the patient was managed conservatively with parenteral nutrition and close observation. A water-soluble contrast enema and computed tomography of the abdomen were of no help in identifying the cause of his pneumoperitoneum but were helpful in eliminating the presence of hollow viscus perforation or an obvious inflammatory focus. The aetiology of pneumoperitoneum in our patient was most likely due to dissection of air through the distended colonic wall, secondary to large bowel pseudo-obstruction. The diagnosis of spontaneous or non-surgical pneumoperitoneum is one of exclusion and we stress the importance of relying on clinical parameters when managing such patients conservatively.     

Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma

INTRODUCTION

Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen.

PRESENTATION OF CASE

We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed.

CONCLUSION

Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.     

Radiologic pneumoperitoneum without perforation of a hollow viscus

About 10% of the radiological pneumoperitoneums occur without hollow viscus perforation. Pseudopneumoperitoneum is defined when the subphrenic lucency does not correspond to free intraperitoneal air: subphrenic fat pad, linear lung atelectasis, abnormal subphrenic shape, Chila?diti syndrome or subphrenic abscess. True pneumoperitoneum without hollow viscus perforation may result from diffusion of thorax-derived air through a phrenic defect or along sheaths of mediastinal blood vessels. The female genital tract represents another route for intraperitoneal air penetration. Other etiologies include iatrogenic pneumoperitoneum (after abdominal surgery and digestive endoscopy) and pneumatosis cystoides intestinalis, when the subserous intraparietal gaseous bubbles rupture into the peritoneal cavity.     

Pneumoperitoneum Following the Spontaneous Rupture of a Gas-Containing Pyogenic Liver Abscess: Report of a Case

We report herein the case of a ruptured liver abscess that resulted in pneumoperitoneum. A patient with diabetes mellitus presented with symptoms of acute abdomen. The plain abdominal radiograph and computed tomography findings revealed abdominal free air and a gas-containing liver abscess, whereby a diagnosis of a ruptured liver abscess was made. An emergency operation was performed, and the abscess was drained followed by peritoneal lavage and the administration of appropriate antibiotics. To the best of our knowledge, very few cases of spontaneous pneumoperitoneum occurring secondary to the rupture of a gas-containing liver abscess have been encountered in Japan. Received: February 10, 2000 / Accepted: July 25, 2000     

Development of pneumoperitoneum after CPR

INTRODUCTIONChest compressions are performed routinely and have several well-known complications, however one of the rare complications is pneumoperitoneum caused by air entry through a perforation of the viscus. The exact cause of the perforation is not always clear. Furthermore, this rarely reported condition does not have clear management guidelines.PRESENTATION OF CASEWe present an uncommon complication of pneumoperitoneum following successful resuscitation possibly caused by the presence of an orogastric tube at the time of compressions in a 79 year old Hispanic male. Following chest compressions, a distended and tympanic abdomen was noted and air seen under the diaphragm in X-ray imaging.DISCUSSIONA review of previous case reports along with etiology and evaluation of risk factors is presented.CONCLUSIONAlthough the exact cause of pneumoperitoneum cannot be confirmed, emergency personnel should be aware of the risk factors associated with viscus perforation during chest compressions.     

Pneumoperitoneum and peritonitis secondary to perforation of an infected bladder

Introduction and importanceSpontaneous urinary bladder rupture is a rare complication of urosepsis. Its co-occurrence with pneumoperitoneum is even more unusual.Case presentationA 73-year-old patient presented with acute retention with mild lower abdominal pain and difficulty with urinary voiding and cystitis. He was treated with bladder catheter and antibiotics. After one month, he suddenly developed peritonitis and shock. Pneumoperitoneum was observed on a chest x-ray. An emergent laparotomy was performed and a perforation of the bladder secondary to necrosis of part of the wall was found and resected. The patient recovered satisfactorily after the surgical intervention.Clinical discussionSpontaneous bladder rupture is a life-threatening condition that could be missed. Surgical intervention is mandatory to rule out other more probable causes of peritonitis and to manage the bladder perforation itself.ConclusionPneumoperitoneum is rarely secondary to a bladder perforation. Immediate surgical intervention is required in order to avoid delays in treating any intra-abdominal condition including a bladder wall perforation.     

Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: Difficulty in diagnosis

Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. He had been receiving nocturnal intermittent PD for 2 years and had ischemic heart disease and cirrhosis of the liver. Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The “board-like abdomen” sign was not noted. Air inflation and contrast radiography indicated a perforation in the upper gastrointestinal tract, and laparotomy disclosed a perforation in the prepyloric great curvature. Unfortunately, the patient died during surgery. This case illustrates that the “board-like abdomen” sign may be absent in PD patients with PPU because of dilution of gastric acid by the dialysate. Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.     

Pneumoperitoneum after cardiopulmonary resuscitation: a therapeutic dilemma

We report a patient who developed pneumoperitoneum after cardiopulmonary resuscitation. Ten cases have been reported in the literature. Despite the patient's serious condition, celiotomy was performed to rule out perforation of a hollow viscus and none was found. The likelihood of visceral perforation in this setting is high and despite increasing recognition of pneumoperitoneum that does not require surgical intervention, nonoperative management should not be entertained in this setting unless visceral perforation can be excluded.     

Recurring spontaneous aseptic pneumoperitoneum presenting secondary to an unrelated chief complaint: A case report

INTRODUCTIONPneumoperitoneum, observed by radiography, is typically associated with the perforation of hollow viscous. More than 90% of all cases of pneumoperitoneum are the result of a gastrointestinal tract perforation. These patients usually present with signs of acute peritonitis and require immediate surgical exploration and intervention. However, rare cases of idiopathic spontaneous pneumoperitoneum do occur without any indication of visceral perforation and other known causes of the free intraperitoneal gas.PRESENTATION OF CASEA 66-year-old male presented to the emergency department on three separate occasions with similar episodes six months apart. Upon physical examination and subsequent testing, chest radiography revealed the presence of free intraperitoneal gas. A computerized tomography (CT) was performed in which pneumatosis and pneumoperitoneum was reported with the first two admissions and both laparotomies were negative. This patient continues to be followed for prostate cancer and bony metastases. All subsequent CT scans (last performed 01/2014) have shown no acute or chronic abdominal pathology and no obstructions. He also had upper and lower endoscopies in 2011, which were negative.DISCUSSIONThis case revealed very different finding than anticipated. The patient presented to the emergency department with symptoms unrelated to the CT findings of free intraperitoneal gas. On two separate occasions, the patient underwent a laparotomy with negative findings. The conventional course of treatment for pneumoperitoneum was followed, but was it necessary? Though the presentation of pneumoperitoneum is most often associated with significant pathology requiring surgical intervention, a more conservative approach may be applicable in cases similar to the one presented here.     

Acute diffuse peritonitis due to spontaneous rupture of a primary gastrointestinal stromal tumor of the jejunum: A case report

IntroductionGastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Overt peritonitis caused by GIST rupture is very uncommon. Three types of GIST rupture have been described: closed perforation due to abscess (abscess type), hemoperitoneum leading to rupture of the hematoma capsule in the tumor (hemoperitoneum type), and perforation of the digestive tract via a fistula leading to central necrosis of the tumor (bowel perforation type). This report describes a patient with spontaneous tumor rupture and diffuse peritonitis, a variant of the bowel perforation type of GIST rupture.Presentation of caseA 74-year-old man presented with symptoms of vomiting and abdominal pain. Computed tomography (CT) scan revealed an approximately 10 × 7-cm mass in the pelvis with free air and fluid collection. Emergency laparotomy revealed a tumor in the jejunum, which was ruptured with a hole measuring 5 mm in diameter. The tumor and part of the jejunum were resected. Immunohistochemically, the mass was diagnosed as a GIST originating from the gastrointestinal tract. Despite chemotherapy with imatinib mesylate, the patient died 22 months after surgery.ConclusionsThis report describes a patient with acute diffuse peritonitis due to spontaneous rupture of a primary GIST of the jejunum.     

Ruptured amebic liver abscess

Fifteen cases of extrahepatic rupture of amebic liver abscess have been reviewed. Five patients had thoracic rupture and ten had intra-abdominal rupture. Celiotomies were performed in five patients, with a preoperative diagnosis of acute appendicitis with perforation in four patients and generalized peritonitis of unknown origin in one patient. All 15 patients were treated with amebicides, including three patients with documented free intraperitoneal perforation who were not treated surgically. Twelve patients recovered uneventfully. Two patients with thoracic rupture developed secondary bacterial complications and in one case of free intraperitoneal rupture, a mistaken diagnosis of ruptured pyogenic abscess was made. Amebicidal therapy was delayed for four days. The patient died of multisystem organ failure. Amebicidal therapy is effective in the treatment of both unruptured and extrahepatic rupture of amebic liver abscess. Surgery should be required only for secondary bacterial complications.     

Non-surgical pneumoperitoneum after oro-genital intercourse

INTRODUCTIONIn many cases, a pneumoperitoneum is due to air escaping from a perforated hollow viscus or surgical intervention but there are increasing reports of non-surgical causes.PRESENTATION OF CASEWe report a case where a pneumoperitoneum was identified after oro-genital sexual intercourse.DISCUSSIONThere were nineteen reported cases of non-surgical pneumoperitoneum from gynaecologic causes up to May 2013. We report an additional case four hours after oro-genital intercourse. Close clinical observation and symptomatic treatment are usually all that is required but operative interventions should be considered if the patient develops abdominal pain, peritoneal signs, fever or leukocytosis during observation.CONCLUSIONThis adds to the world literature on non-surgical pneumoperitoneum from oro-genital intercourse. Clinicians should be aware of this condition and focus on medical-sexual history as this information could prevent a patient from being exposed to expensive diagnostics and invasive operative treatments. Patients should also be educated about the mechanisms to avoid future possible diagnostic dilemmas.     

Postcoital pneumoperitoneum after hysterectomy

Usually, pneumoperitoneum is a serious condition suggesting a perforation of the abdominal viscus. Nonsurgical pneumoperitoneum accounts for approximately 10% of all cases. The authors present a case of postcoital pneumoperitoneum after a hysterectomy. A 46-year-old woman presented to the emergency department 4 months after an abdominal hysterectomy with complaints of abdominal discomfort and radiographic evidence of free air under the diaphragm. The clinical finding did not support the radiographic evidence. An unclear peptic ulcer history led us at first to mistakenly diagnose a covered perforation of gastroduodenal ulcer. Diagnostic perplexity forced us to perform a laparoscopy after 30 h. The abdominal cavity was surprisingly normal, and no perforation was found. Nonsurgical postcoital pneumoperitoneum is rare. We solved such a case for the first time. By means of laparoscopy, we could exclude perforation of the viscus and peritonitis, and the operation was carried out in a minimally invasive way.     

Pneumoperitoneum: is exploratory laparotomy always indicated?

Pneumoperitoneum usually indicates a surgical emergency because of visceral perforation in 85 to 95% of cases. Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma for the surgeon who is faced with this problem. Some cases of pneumoperitoneum can and should be managed conservatively. We report three cases of pneumoperitoneum and describe their outcomes. Two cases were treated conservatively, and one underwent laparotomy but no perforated viscus was found. We review the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. Furthermore, a compilation of other aetiologies of pneumoperitoneum without peritonitis as reported in the literature is presented. Pneumoperitoneum, preceded by a reasonable clinical history in a patient with an adequate abdominal examination, may warrant continued observation, thus avoiding an unnecessary laparotomy.