Pneumoperitoneum and its association with ruptured abdominal viscus

Pneumoperitoneum is not invariably associated with ruptured or perforated intra-abdominal viscus. To determine the incidence of free air associated with intra-abdominal viscus perforation, the medical records of 77 consecutive patients whose discharge or autopsy diagnosis included pneumoperitoneum or perforated viscus at a community hospital were retrospectively reviewed between June 1980 and October 1985. Abdominal viscus perforation, as determined by contrast studies or at operation, was not invariably associated with free air. Sixty-nine percent (23/33) of gastroduodenal, 30% (3/10) of small-bowel, and 37% (11/30) of large-bowel perforations had free air, as determined by preoperative x-ray film. Four cases with a total of six episodes of pneumoperitoneum were identified where viscus perforation was not documented. Pneumoperitoneum thus remains a reliable sign of viscus perforation; however, lack of this finding does not rule out perforation, and unusual causes must be considered.     

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.     

Incidence and significance of pneumoperitoneum after inguinal herniorrhaphy

Previous studies have shown pneumoperitoneum either to be extremely rare or to not occur after inguinal herniorrhaphy, and that its presence signifies a serious intra-abdominal complication. A prospective study has been carried out to consider the incidence and significance of pneumoperitoneum after herniorrhaphy for indirect inguinal hernias. In a 1-year period, 100 patients were studied. Pneumoperitoneum was detected in six patients. In five patients, the amount of free gas was minimal and was reabsorbed after 48 h. The pneumoperitoneum was large and of increasing amount in one patient. Faecal fistula developed 7 days after operation due to an injury from the hernial repair to the sigmoid colon. The result of this study suggested that detectable pneumoperitoneum of small amount may be present after inguinal herniorrhaphy and, if it persists for longer than 48 h, the presence of a perforated viscus should be considered.     

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.     

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.     

Pneumoperitoneum without perforation of the gastrointestinal tract

Pneumoperitoneum (PP) is usually the result of perforation of the gastrointestinal (GI) tract with associated peritonitis. However, other rare causes, including spontaneous PP incidental to intrathoracic, intra-abdominal, gynecologic, and miscellaneous other origins not associated with a perforated GI tract have been described in the literature. Six cases of PP without any perforated GI tract are reported. Three patients with generalized peritonitis underwent exploratory laparotomy or laparoscopy when clinical examinations suggested an acute abdomen. At surgical procedure, perforated pyometra, perforated liver abscess and a ruptured necrotic lesion of a liver metastasis were documented in these patients, respectively. We also saw 3 PP patients not associated with peritonitis. Two patients with PP caused by pneumatosis cystoides intestinalis were encountered, 1 was managed conservatively and the other received diagnostic laparoscopy. A patient in whom pneumomediastinum and pneumoretroperitoneum were accompanied by PP caused by an alveolar rupture based on decreased pulmonary compliance due to malnutrition was managed conservatively. The history of the patient and knowledge of the less frequent causes of PP can possibly contribute towards refraining from exploratory laparotomy in the absence of peritonitis.     

Spontaneous pneumoperitoneum in pediatric patients: A case series

IntroductionPneumoperitoneum frequently results in emergent surgery because it typically indicates an abdominal viscus perforation. However, this may not always be the case. There have been few recent reports in the pediatric population that document cases of pneumoperitoneum which could be considered for non-surgical management.Presentation of caseThis case series presents three different instances of pediatric patients with radiographic evidence of pneumoperitoneum who were subsequently found to have no perforated viscus following surgical intervention.ConclusionWe recommend that in the absence of peritoneal signs, fever, leukocytosis, significant abdominal pain, distension, or clinical deterioration, non-operative management be considered in pediatric patients with radiographic signs of pneumoperitoneum.     

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.     

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.     

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.     

Postoperative Pneumoperitoneum: An Unusual Etiology

Although postoperative pneumoperitoneum is a common finding, it is particularly disturbing when there is an increase in the amount of postoperative pneumoperitoneum or when the radiographic finding of pneumoperitoneum is accompanied by such physical findings as increased abdominal tenderness, peritoneal signs or paralytic ileus. Four patients operated upon at the Mount Sinai Hospital are presented. All patients underwent abdominal surgery for treatment of some form of inflammatory bowel disease and all were receiving systemic corticosteroids in the postoperative period. Abdominal findings of tenderness, ileus and peritoneal irritation developed shortly after the removal of Penrose drains in the postoperative period. Pneumoperitoneum was confirmed by abdominal roentgenographs. The first patient in this group underwent a laparotomy with essentially negative findings other than a freely open drain tract. The subsequent three patients were managed by close observation and frequent abdominal radiographs. These three patients had contrast roentgenographic studies of the upper gastrointestinal tract to rule out perforation of a peptic ulcer, and in the patient upon whom reservoir ileostomy had been performed, a contrast study of the reservoir was performed. All patients recovered fully with this management and there were no sequelae. The mechanism for the appearance of pneumoperitoneum after removal of drains, particularly when the patient is receiving systemic corticosteroids, is discussed. Emphasis is placed on the need to consider and rule out perforation of a hollow viscus in this situation before accepting drain removal as the sole cause of post-operative pneumoperitoneum.     

Value of pneumoperitoneum in the diagnosis of visceral perforation

The presence or absence of pneumoperitoneum may not be as reliable an indicator of visceral perforation as commonly thought. Visceral perforation as commonly thought. Visceral perforation resulted in pneumoperitoneum in only 51 percent of patients in this study. Pneumoperitoneum occurred in 14 percent of patients in whom the extraalimentary intraperitoneal air had sources other than a perforated viscus. These patients' clinical findings were often indistinguishable from those of patients with a perforated viscus, and three patients underwent celiotomy unnecessarily. The routine use of the left lateral decubitus film to detect pneumoperitoneum and the judicious use of gastrointestinal contrast studies should be part of the optimal management of patients with suspected visceral perforation.     

Radiographic pneumoperitoneum following abdominal stab wound is not an absolute indication for mandatory laparotomy – A South African experience

IntroductionPneumoperitoneum on chest radiograph (CXR) following abdominal stab wounds (SW) is generally considered as surrogate evidence of viscus perforation and an absolute indication for laparotomy. The exact yield of this radiographic finding is unknown.Materials and methodsA retrospective study was conducted on all patients who presented with abdominal SW with no peritoneal signs but had pneumoperitoneum alone who underwent mandatory laparotomy from December 2012 to October 2020 at a major trauma centre in South Africa.ResultsDuring the 8-year study period, 55 patients were included (91% male, mean age: 24 years). Laparotomy was positive in 67% (37/55). Of the 37 positive laparotomies, 28 (76%) were considered therapeutic and the remaining 9 (24%) were nontherapeutic. The negative laparotomy rate was 33%. A total of 52 organ injuries were identified at laparotomy in the 37 positive laparotomies. Twenty-five per cent (14/55) of patients experienced complications. The complication rate of the subgroup of 18 patients who had a negative laparotomy was 33% (6/18). Two per cent (1/55) of all 55 patients required intensive care admission. The mean length of hospital stay was 6 days. There were no mortalities in this cohort.ConclusionsPneumoperitoneum alone in patients with no peritoneal signs on initial assessment following abdominal SW cannot be considered an absolute indication for operative exploration. Up to one third of patients have no intra-abdominal injuries. This specific subgroup of patients can potentially be managed by a selective non-operative management approach.     

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.     

Free intraabdominal air following an isolated gunshot injury to the trachea

This case report describes a 21-year-old male patient suffering from a close-range suprajugular blank-cartridge injury, i.e. a gunshot injury without a projectile. On arrival at the hospital a cutaneous lesion of 5 mm in diameter was seen 2 cm above the jugular notch with traces of gunpowder in the surrounding skin. The cardiovascular status and spontaneous breathing were sufficient. On attempts to answer questions air was seen to escape from the lesion, indicating a tracheal defect. The patient was rapidly intubated and subjected to further diagnostic procedures. A chest X-ray film revealed bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and marked subcutaneous emphysema of the chest and abdominal wall. After insertion of bilateral chest tubes, both lungs promptly reinflated and no air leakage could be demonstrated. As free intra-abdominal air has its source in a ruptured viscus in about 90% of cases, close attention was paid to possible abdominal symptoms. Contrast radiography and computer tomography (1st postoperative day) failed to demonstrate intestinal rupture. As there was no clinical evidence of peritonitis, exploratory laparotomy was not performed. Revision of the cervical lesion revealed locally extended destruction of tissues, including the pyramidal thyroid lobe and the anterior tracheal wall. After anastomosis of the trachea the endotracheal tube was left in place as an intraluminal splint for 8 days. Bronchoscopy at this time showed no evidence of tracheal stenosis and the patient was extubated. Two days later he left the hospital. The underlying pathophysiological mechanisms of free intra-abdominal air in the absence of gastrointestinal lesions are discussed and the literature is reviewed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recurrent "spontaneous" pneumoperitoneum: a diagnostic and therapeutic dilemma

The finding of intraperitoneal free gas usually indicates a perforated abdominal viscus, and requires emergency surgery. In a minority of cases, no perforation can be found, a situation that can be classified as "spontaneous" pneumoperitoneum. A conservative approach may be considered if clinical signs are minimal, particularly when peritoneal signs, fever and leucocytosis are absent. The various causes of spontaneous pneumoperitoneum are discussed.     

Recurrent “spontaneous” Pneumoperitoneum: a Diagnostic and Therapeutic Dilemma

The finding of intraperitoneal free gas usually indicates a perforated abdominal viscus, and requires emergency surgery. In a minority of cases, no perforation can be found, a situation that can be classified as “spontaneous” pneumoperitoneum. A conservative approach may be considered if clinical signs are minimal, particularly when peritoneal signs, fever and leucocytosis are absent. The various causes of spontaneous pneumoperitoneum are discussed.     

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.     

Acute recovery of pneumoperitoneum using argon gas

BACKGROUND AND PURPOSE: The argon-beam coagulator (ABC) is widely used in laparoscopic surgery as a method of electrocoagulation. Argon gas possesses properties that make it suitable as an alternative for establishing pneumoperitoneum. We present a case in which an ABC was used to deliver argon gas urgently in order to salvage an acutely compromised pneumoperitoneum. METHODS: During a right partial nephrectomy, after the renal artery was clamped, a failure in the central CO(2) compressor compromised the pneumoperitoneum. Argon gas was delivered from an ABC at a flow rate of 4 L/min and a distance of 1 to 5 cm and directed toward the paranephric fat. RESULTS: Pneumoperitoneum was rapidly reestablished. Stable intra-abdominal pressure was maintained in the range of 14 to 20 mm Hg for 16 minutes until the original CO(2) supply was reestablished. The total warm ischemia time was 32 minutes. No hemodynamic changes were noted while using argon gas, and the procedure was completed successfully with an uneventful postoperative course. CONCLUSIONS: Argon gas delivery from an ABC can be used for emergency salvage of pneumoperitoneum in selected cases of acute CO(2) gas delivery failure and under strict intra-abdominal pressure monitoring.