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     

Unusual pneumoperitoneum secondary to ruptured liver abscess-A case report

IntroductionPyogenic liver abscess is important cause of hospitalization and life threatening disease in low-middle income countries. Clinical spectrum of ruptured GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis.Case presentationWe reported here a case with pneumoperitoneum caused by ruptured liver abscess in a 27-year-old man with a history of uncontrolled type II diabetes mellitus. He had an abdominal pain, distension of abdomen associated with a high fever. Patient was diagnosed peritonitis and pneumoperitoneum presumed to be secondary to perforation of a hollow viscus and subjected to emergency laparotomy. We did not find any gastrointestinal perforation. Surprisingly, we detected a ruptured liver abscess in the right lobe of the liver.. The patient was in septic shock and hence shifted to ICU with inotropic support. Antibiotic therapy was started according to pus culture sensitivity. Even with the above treatment patient was not improved and on 4th postoperative day the patient collapsed and declared dead.DiscussionPneumoperitoneum secondary to ruptured gas containing pyogenic liver abscess is rare and could represent as life threatening infection. It should be distinguished from perforation of hollow organ by clinical symptoms and image examinations, particularly like CT. Accurate diagnosis with adequate drainage and antibiotic therapy would bring good outcome.ConclusionWe are aware that not every case of pneumoperitoneum is attributable to a perforated hollow viscus. A rapid and prompt surgical intervention with appropriate antibiotics are essential to save a life.     

Pneumoperitoneum caused by ruptured gas-containing liver abscess

An 84-year-old woman was admitted to our hospital with high fever, and she suddenly complained of severe abdominal pain the next day. Computed tomography revealed a gas-containing abscess in the lateral segment of the liver, with spontaneous pneumoperitoneum. An emergency lateral segmentectomy was performed, and Klebsiella pneumoniae was cultured from the liver tissue, abscess, and blood. The patient made a satisfactory recovery and was discharged on the thirty-first postoperative day. Pneumoperitoneum caused by the rupture of a gas-containing liver abscess is rare, and to our best knowledge, this is the first report, in the English-language literature, of a patient who has undergone successful hepatectomy for such a condition.     

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.     

Gas-containing pyogenic liver abscess —A case report and review of the literature—

The incidence of gas-containing pyogenic liver abscess is exceedingly rare. We report herein, a case of a 36 year-old Japanese woman with a gas-containing pyogenic liver abscess associated with diabetes mellitus and cholelithiasis. An abdominal plain X-ray film, which showed a fine air-fluid level in the liver at an up-right position, enabled us to easily diagnosed a gas-containing liver abscess. Echo-guide percutaneous drain-age revealed the organism to beEscherichia coli, however, although this treatment has recently been employed often in the treatment of pyogenic liver abscesses, especially single abscesses, it did not prove effective in this case. We finally cured the gas-containing pyogenic liver abscess by operative drainage.     

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.     

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 after rough sexual intercourse

Our objective is to report on a case of nonsurgical pneumoperitoneum and review the mechanism/gynecologic causes of such. We present a case report and review of the literature based on a MEDLINE search using the keywords pneumoperitoneum and nonsurgical. Radiographic evidence of free intraperitoneal air suggests hollow viscus rupture and usually warrants urgent surgical management. Findings of diffuse rebound tenderness and guarding solidify the decision for urgent surgical exploration. We present a case of a patient who presented with all of the above findings that subsequently underwent a negative laparotomy. On the day after surgery she admitted to having had rough sexual intercourse 3 days before presentation. Nonsurgical pneumoperitoneum has a number of unusual causes. Intra-abdominal, thoracic, gynecologic, iatrogenic, and miscellaneous etiologies are encountered. It was determined that the pneumoperitoneum in this case was secondary to rough sexual intercourse. We concluded that pneumoperitoneum secondary to nonsurgical causes represents a diagnostic dilemma. In the patient with free intraperitoneal air on plain X-ray one should be suspicious of less common nonsurgical etiologies. The majority of patients will require laparotomy. Thorough sexual and gynecologic/obstetrical history is a valuable adjunct in identifying the patient who does not.     

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.     

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 without peritonitis.

Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma to the surgeon faced with this problem. Two such cases and their outcome are presented. The first case was caused by barotrauma during positive pressure ventilation and was treated by laparotomy. No perforated viscus was found. The second case was caused by tracheal rupture during emergency intubation and was treated by observation until complete resolution. Both patients died for reasons unrelated to the pneumoperitoneum. The mechanisms for passage of air from the chest into the abdominal cavity were through the diaphragm in the first case and along the great vessels in the second. A compilation of other etiologies of pneumoperitoneum without peritonitis as extracted from the literature is presented. In the presence of pneumoperitoneum without peritonitis and when the clinical history does not suggest perforation of a viscus, we advise performing an abdominal tap. If negative, continued observation is advised.     

Spontaneous rupture into the peritoneal cavity: Unusual presentation of prostatic abscess

IntroductionProstatic abscess is a rare but relatively serious infectious disease; its association with spontaneous rupture is extremely unusual.Presentation of caseWe present a case of peritonitis secondary to a rupture of prostatic abscess in a 87-year-old man. The diagnosis was made on computed tomography. Emergency laparotomy, transrectal ultrasonography guided aspiration of the residual abscess and antibiotics permitted a full recovery.DiscussionDelay in diagnosis of prostatic abscess can have grave sequelae, including spontaneous rupture into the urethra, perineum, bladder or rectum and the development of septic shock. Only one case of spontaneous rupture into the peritoneal cavity has been reported in the literature.ConclusionThis case highlights the importance of early diagnosis of prostatic abscess and close monitoring of patients, with diabetes or immunosuppression, treated for acute prostatitis.     

Spontaneous Cutaneous Rupture of a Pyogenic Liver Abscess

Spontaneous rupture of a pyogenic liver abscess is a rare entity reported. Spontaneous cutaneous rupture of a pyogenic liver abscess is even a rarer clinical entity not well documented in the literature. A patient having spontaneous cutaneous rupture of a pyogenic liver abscess is reported. The condition is rare and serious because of the possible delay in diagnosis. Recently, with the advent of ultrasound (USG) and computed tomography (CT) scan, there has been improvement in the rate of early diagnosis of liver abscess as well as in prognosis. The clinical presentation is variable; in some cases there are delays, misdiagnoses, or incidental recovery. Per cutaneous catheter drainage under USG or CT guidance has become the standard of care.     

Contained rupture of a myocardial abscess in the free wall of the left ventricle

Contained rupture of the left ventricle is uncommon; rupture secondary to a myocardial abscess is exceedingly rare. A case is presented of a contained rupture of a myocardial abscess in a patient with Staphylococcus aureus septicemia. The rupture was repaired surgically, and the patient survived.     

Pneumoperitoneum from gas gangrene of the pancreas: three unusual findings in a single case

A 62-year-old man was first seen with acute pancreatitis with diffuse intrapancreatic gas and pneumo-peritoneum. An immediate exploratory operation revealed diffuse pancreatic necrosis but no perforated viscus; postoperatively, the patient rapidly died. This case represents a constellation of extremely rare findings: Clostridium perfringens infection of the pancreas, pancreatic emphysema or "gas gangrene," and pneumoperitoneum without a perforated viscus.     

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.     

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.     

Myocardial abscess with contained rupture: successful repair

Spontaneous rupture of the heart from myocardial abscess is a rare occurrence. Most cases of spontaneous cardiac rupture are due to myocardial infarction. We present a case of a contained rupture of the heart in a patient with staphylococcal septicemia. Although cultures from the pericardial space were negative the macroscopic and clinical picture was compatible with an abscess.     

Maduromycosis of the brain. Case report.

A rare case of a gas-containing brain abscess due to verified maduromycosis is described. Blackish material over the abscess cavity revealed the fungal elements. The pus from the abscess contained Streptococcus hemolyticus and Klebsiella organisms.