A case report of the transport of an infant with a tension pneumopericardium

Neonatal pneumopericardium is a potentially fatal complication of positive-pressure ventilation and has become rare with the advent of surfactant replacement therapy. The clinical diagnosis, stabilization, treatment, and nursing care of an infant with pneumopericardium has not previously been discussed in the nursing literature. In this case report, delays in the recognition and definitive treatment of the pneumopericardium were encountered, resulting in the transport of an infant with a tension pneumopericardium and pneumoperitoneum. Root-cause analysis is used to identify contributing factors and examine system changes necessary to prevent the transport of another patient with a similar potentially life-threatening condition. Pneumopericardium should be suspected in any infant with an acute deterioration, especially in the presence of normal, equal breath sounds and muffled heart sounds, because prompt recognition and definitive treatment may be life-saving.

Chilaiditi's syndrome: what should every surgeon know?

Demetrius Chilaiditi first described an incidental radiological finding of hepatodiaphragmatic interposition of bowel in 1910. The condition could be mistaken for pneumoperitoneum. This radiographic entity, known as Chilaiditi's sign, is found in asymptomatic patients and must be distinguished from Chilaiditi's syndrome, which produces symptomatology associated with the bowel interposition. A review of the literature yielded 27 published cases of Chilaiditi's syndrome. These cases were compiled to evaluate various aspects of this rare but important entity.

Liver metastasis presenting as pneumoperitoneum

A 63-year-old man presented to the emergency department with sudden-onset abdominal pain. Chest radiography demonstrated pneumoperitoneum. At surgery, the source was found to be a ruptured hepatic abscess. Cultures grew Clostridium perfringens, and biopsies confirmed metastasis of a previously resected pancreatic cancer. We document this rare cause of pneumoperitoneum and briefly review the literature on liver abscess as it relates to metastatic cancer.

Necrotizing Enterocolitis: Assessment of Bowel Viability with Color Doppler US

PURPOSE

To determine whether absence of bowel wall perfusion at color Doppler ultrasonography (US) is indicative of bowel necrosis in neonates with necrotizing enterocolitis (NEC).

MATERIALS AND METHODS

This study was approved by the research ethics board, and informed consent was obtained. Sixty-two neonates enrolled in the prospective study underwent US of the bowel wall. Neonates were divided into two groups. Group A included 30 control subjects with gestational ages (GAs) ranging from 24 to 41 weeks. Group B included 32 neonates with GAs ranging from 24 to 40 weeks who were clinically proved to have or suspected of having NEC. All neonates in group B underwent abdominal radiography. Normative values were calculated in group A. In group B, the sensitivities and specificities of color Doppler US and abdominal radiography for detection of bowel necrosis were computed by using the modified Bell staging criteria for NEC as the reference standard.

RESULTS

Two neonates were excluded from group B; thus, a total of 60 neonates were included in the study. In group A, bowel wall thickness ranged from 1.1 to 2.6 mm. Bowel wall perfusion was detected with color Doppler US in all 30 neonates. Color Doppler signals ranged from one to nine dots per square centimeter. Twenty-two of 30 neonates in group B received a diagnosis of NEC. Mild to moderate NEC was diagnosed in 12 neonates. Color Doppler US depicted an isolated segment of bowel-absent blood flow in two neonates; this finding was confirmed with laparotomy. In 10 neonates with severe NEC, color Doppler US depicted isolated or multiple segments of bowel with absent perfusion. Pneumoperitoneum was present in only four neonates. The remaining eight neonates at risk for NEC had no evidence of loops without perfusion at color Doppler US. The sensitivity of free air at abdominal radiography as a positive sign for severe NEC with necrotic bowel was 40% compared with the 100% sensitivity of absence of flow at color Doppler US (P = .03).

CONCLUSION

Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC.

Stent-graft treatment of complete acute aortic transection complicated by intussusception and pseudo-coartaction

Aim of the study was to validate the use of endoluminal stent-graft treatment as an alternative to conventional surgery in patients affected by blunt chest trauma and aortic disruption with multiple associated lesions. We report the case of a young female admitted with diagnosis of descending thoracic aortic transection and multiple traumas following a car accident. Spiral computed tomography revealed circular disruption of thoracic aorta immediately after isthmus region with intussusception of leaflets and pseudo-coartation. Doppler analysis showed a 70 mmHg transaortic gradient. The hemodynamic evaluation confirmed the existence of severe transaortic gradient. A Gore-TAG endoprosthesis (26 x 100 mm) was selected. Intraoper-ative transesophageal echocardiography assessment was performed to monitoring the entire procedure. The final arteriogram showed an optimal sealing at proximal and distal site without endoleak with complete readjustment of intimal leaflets to the aortic wall and disappearance of transaortic gradient related to the pseudo-coartation. No complication was observed in the early postoperative and patient was discharged one month later once complete rehabilitation of associated lesion was obtained. Computed tomography scan performed before discharge revealed persistency of patent lumen of aorta with fibrosis of readjusted circumferential intimal flap. In conclusion endovascular repair of complete aortic transection may result safe and effective particularly in patients with extensive associated injuries. Indeed the severity of coexisting non-aortic lesions could be adversely affected by conventional surgery in consideration of high surgical morbidity due to open thoracotomy. Stent-graft repair allows the patient to timely undergo medical or surgical management of associated lesions and a prompt rehabilitation with shorter hospital stay.

[Diagnostic image (232). A neonate with bilious vomiting]

A prematurely born girl presented with abdominal distension, bilious vomiting and a football sign on a plain abdominal X-ray, due to accumulation of free gas following infarction and perforation of the ileum: a complication of indomethacine.

Histoplasmosis presenting as pneumoperitoneum in patients with acquired immune deficiency syndrome: case reports and review of the literature

Histoplasmosis is a rare, but important, disease process in patients with the acquired immune deficiency syndrome (AIDS). Initially reported in this patient population in 1982, over 100 cases of histoplasmosis have been reported throughout the United States. Most of these patients present with disseminated disease. Untreated, histoplasmosis will be the direct cause of death in over 80% of patients, but treatment with itraconazole can reduce this mortality to less than 25%. We present two cases of histoplasmosis in AIDS patients presenting as pneumoperitoneum.

[Pneumatosis cystoides intestinalis, as a rare complications of coeliac disease]

Intestinal pneumatosis cystoides is rarely diagnosed clinical entity characterized by multiple gas containing cysts inside the wall of the gastrointestinal tract. Primary (15%) and secondary (85%) forms are known. In the more frequent secondary forms small intestine and the right side of the colon are mainly affected, and the underlying pathology can be gastrointestinal, pulmonary or immunological. The 64 year old male patient reported by the authors showed clinical signs of severe malabsorption (his body weight: 47,5 kg, height: 178 cm, BMI: 15). The intestinal pneumatosis was diagnosed by exploration performed because of suspected perforation (pneumoperitoneum). Due to severe malabsorption the patient was admitted to Gastroenterological Department. Duodenoscopy and small bowel biopsy was performed. Small intestinal histology and presence of anti-gliadin and anti-endomysium antibody confirmed the suspected diagnosis of coeliakia. Parenteral nutrition, special gliadin free diet, hyperbaric oxygen inhalation, steroid, and metronidazole treatment resulted in a gradual improvement in the nutritional and general condition of the patient. After one year the patient is without complaints, he gained 24,5 kg body weight BMI: 22,5). The author's case points to a rare serious complication of non-treated coeliakia. Recognition of intestinal pneumatosis in time could have prevented surgical intervention in the high risk patient.

Pneumoretroperitoneum in two patients with Clostridium perfringens necrotizing pancreatitis

Pancreatic gas gangrene is an uncommon and often fatal complication of acute pancreatitis, due to the sporulating anaerobe Clostridium perfringens. C. perfringens is a normal constituent of colonic flora, but infects the pancreas by either transmural spread from the colon or via the biliary tree. Only three reported cases in the world literature describe acute pancreatitis with pneumoretroperitoneum and clostridial infection. Two separate cases, at the same institution, of acute pancreatitis complicated by C. perfringens were analyzed. The records of patients were reviewed for admission history, laboratory and radiology results, intensive care support, surgical intervention, and outcome. Retroperitoneal air was visualized early in the clinical course of both patients by computed tomography. Early surgical debridement, drainage, parental antibiotics, and reexploration resulted in an uncomplicated recovery. Early computed tomography in patients with suspected necrotizing pancreatitis contributes to early intervention and may advantageously enhance survival.

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.

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.

Massive pneumoperitoneum after scuba diving

Pneumoperitoneum usually indicates rupture of a hollow viscus and considered a surgical emergency. But air may also enter the peritoneum from the lung or the genital organs in female without visceral perforation. While scuba diving, the rapid ascent is usually controlled by placing in a decompression chamber and the excess gas volume is exhaled. Failure to allow this excess gas to escape will result in overdistension of air passage, which may rupture resulting in pulmonary interstitial emphysema or, if air enters the circulation, air embolus can occur. Pneumo-peritoneum is a rare complication of diving accidents. While the majority of cases are not related to an intraabdominal catastrophy, more than 20% have been the result of gastric rupture. We report a 42-yr-old male patient with massive pneumoperitoneum after scuba diving, who presented himself with dyspnea and abdominal distension. Knowledge of this rare condition and its benign course may allow the emergency physician and surgeon to order appropriate studies to help avoid unnecessary surgical treatment. It is important to determine promptly whether the air emanated from a ruptured viscus or was introduced from an extraperitoneal source. Free air in the abdomen does not always indicate a ruptured intra-abdominal viscus.

Pneumatosis cystoides intestinalis coli

The rare case of a 63-year-old male diagnosed with pneumatosis cystoides intestinalis coli is presented and discussed. The patient was found to have an unsymptomatic pneumoperitoneum on plain chest x-ray. The results of a contrast enema, computed tomography scan, and laparoscopy are presented. The patient had an uneventful hospital course without any specific therapy. Causes and possible therapeutic options are discussed.

Spontaneous pneumoperitoneum in two cats

Spontaneous pneumoperitoneum is an infrequently observed presentation in cats. This report details two cases of pneumoperitoneum in the cat. The first case was suspected to have been caused by a gastric perforation secondary to gastric lymphoma. The second case was caused by a perforated gastric ulcer in a cat that had been recently treated with corticosteroids and a non-steroidal anti-inflammatory drug.

Unusual presentation of gastric duplication cyst in a neonate with pneumoperitoneum and vertebral anomalies

An unusual case of communicating, tubular gastric duplication (GD) of the greater curvature of the stomach presenting with pneumoperitoneum is described. The pneumoperitoneum resulted due to simultaneous mechanical rupture of stomach and its duplication cyst due to birth trauma and vigorous post delivery resuscitation. No case of this kind has been reported earlier in English literature, though instances of ulcerative perforation of neonatal stomach and GD are known. There was radiographic evidence of multiple thoracic vertebral anomalies, again a rare occurrence with GD cyst. Further, a diagnostic dilemma was faced in this patient as the presence of radiographic sign of "gastric bubble" on plain radiographs in this patient suggested the source of free intraperitoneal air to be extragastric and the diagnosis could be made only at surgery. The authors have reviewed the pertinent literature on neonatal gastric perforation and GD cysts and uphold "split notochord" theory as etiology for GD in this patient.

["Nonsurgical" pneumoperitoneum]

The authors submit case-histories of patients with an X-ray finding of pneumoperitoneum on a native X-ray of the abdomen. Air in the abdominal cavity was proved in the majority of cases also on laparotomy, however, the source of air was not found. The authors mention four cases from their own department. In the first female patient with a generalized gynaecological tumour pneumoperitoneum was diagnosed repeatedly before surgery. In the second case a female patient was involved with an inoperable pancreatic tumour; obstruction of the biliary pathways was resolved by an endoscopically inserted stent. In that case too the pneumoperitoneum was repeatedly detected before surgery. The third patient with a generalized ovarian tumour, acute abdominal pain and pneumoperitoneum died on the second day after operation. Similarly as patient 2 on necropsy thrombosis of the portal vein was found. In the 4th case the finding of pneumoperitoneum was made after diagnostic technically difficult gastroscopy. This patient was not operated. Patients 1-3 were operated without evidence of perforation of the digestive tract. For illustration cases described in the literature are quoted. The causes of non-surgical pneumoperitoneum are classified according to the anatomical site of development. The author describes the assumed mechanisms of development of non-surgical pneumoperitoneum. In the discussion aspects are mentioned which decide on conservative or surgical treatment of pneumoperitoneum.

[Pneumoperitoneum without perforation of the digestive tract]

The authors present an account on 9 patients who were detected in their department during the nine-year period from 1991-2000 with the finding of pneumoperitoneum where perforation of the digestive tract was not proved. In 4 of them (44%) conservative treatment was used, in the remaining 5 patients (56%) the condition called for surgical revision. The latter was made as an acute operation in four patients because of signs of peritoneal irritation, in one only after 4 days because of suspected tumours intestinal disease. As to the site of the assumed source of the non-perforation pneumoperitoneum we included 6 of them into the group abdominal area, (1x pneumatosis cystoides intestinalis, 1x aerogenic infection from a perforated abscess of the right liver lobe, 2x microtraumas of the wall of the cardio-esophageal transition with massive vomiting, 1x microtraumas of the lesser curvature of the stomach during extreme distension of the stomach after incorrect intubation and resuscitation, 1x passage of gas through the inflamed distended colonic wall in colitis), two patients into the thoracic area (1x in conjunction with pneumothorax, 1x with hydrothorax), 1 patient in the urogenital area (by the gynaecological route after repeated coitus and orogenital practices). The authors summarize on the basis of data in the literature and their own experience diagnostic and therapeutic possibilities of this relatively rare finding.

Use of abdominal percussion for pneumoperitoneum detection

Pneumoperitoneum refers to free air within the abdominal cavity that typically signifies serious abdominal pathology such as a perforated gut. The principal hypothesis of the study was that abdominal structure alterations due to pneumoperitoneum cause diagnostic changes in the sounds induced by abdominal percussion. The current pilot study investigated these changes in a mongrel dog model. Abdominal percussion was performed at baseline and after creation of pneumoperitoneum states. The resulting acoustic events were acquired, digitised and analysed. The event attack and decay rates and dominant frequencies during decay decreased with pneumoperitoneum (p = 0.084, 0.014 and 0.004, respectively; Wilcoxon signed-rank test). Simple theoretical models were constructed and predicted the observed decrease in resonant frequencies with increasing air pocket size. The results suggested that the normal and the 1,000 ml pneumoperitoneum states can be separated using thresholds of the attack and decay rates and resonant frequency (specificity = 80%, 100% and 100%, and sensitivity = 100%, 100% and 100%, respectively). Separating the control and the 500 ml pneumoperitoneum cases may be also possible (specificity = 80%, 100%, 100% and sensitivity = 50%, 70% and 90%, respectively), but separating the two levels of pneumoperitoneum was not feasible using the current approach. Therefore analysis of abdominal percussion sounds may prove useful for pneumoperitoneum detection, but not for distinguishing different levels of that condition.

[Pneumoperitoneum as occasional finding in chronic dialysis patients--laparotomy or conservative non-operative approach?]

Free air of unknown origin within the abdominal cavity is a serious problem, which in the majority of cases indicates the perforation of a hollow organ. In two cases, we report on i) detection of free air subdiaphragmatically by coincidence during follow-up investigation of an interstitial pulmonary disease (chest X-ray) in a 67-year old patient with chronic renal insufficiency, and ii) diagnostic of pneumoperitoneum (3 times as primary diagnosis) in a 63-year old multimorbid female (with chronic renal insufficiency) with recurrent, but unspecific epigastric symptoms over a time period of 5 years. The following investigations such as endoscopy, contrast enema, and abdominal ultrasound did not detect a perforation as most likely cause. The first patient was discharged after clinical observation, laboratory and ultrasound follow-up for 5 days. In the second case, neither explorative laparoscopy during the second clinical observation period nor laparotomy for required cholecystectomy because of cholecystitis could appropriately clarify the origin. In conclusion, the detection of a pneumoperitoneum in asymptomatic patients or subjects with unspecific abdominal symptoms requires always clinical monitoring and instrumental diagnostic, consisting of endoscopy in the upper gastrointestinal tract, contrast enema of the colon and abdominal and/or thoracal computed tomography, to definitely exclude perforation. In addition, ultrasound as third column detects early low amounts of fluid and is the suitable method for short-term follow-up. The cause of pneumoperitoneum, particularly in asymptomatic patients, can not be found in every case. Under these circumstances, non-operative treatment is favored.