Tension pneumoperitoneum: a report of 4 cases

Tension Pneumoperitoneum: A Rare Complication of Cardiopulmonary Resuscitation (CPR)

Tension pneumoperitoneum is a surgical emergency. Although rare, failure to diagnose and treat the condition may be lethal. Hence, being aware of this phenomenon, particularly in scenarios involving cardiopulmonary resuscitation (CPR), is important. Existing literature emphasises immediate abdominal needle decompression as the initial management followed by close monitoring and keeping a low threshold for surgical intervention as a definitive measure. We decided to write up this case report to raise awareness that a tension pneumoperitoneum can result as a complication of CPR, a well-known and widely practiced algorithm.

CT-Guided Percutaneous Drainage of Pneumoperitoneum Presenting as Acute Abdomen

PURPOSE

To evaluate the feasibility and effectiveness of computed tomography (CT)-guided percutaneous drainage (PD) in patients with iatrogenic pneumoperitoneum presenting as acute abdomen.

MATERIALS AND METHODS

In this retrospective, single-center cohort study, 16 consecutive patients (9 males, 7 females; median age, 67.5 [51-85] years) undergoing PD for managing acute abdomen caused by iatrogenic pneumoperitoneum between 2013 and 2019 were analyzed. Inclusion criteria were clinical signs of acute abdomen that was unresponsive to conservative management and pneumoperitoneum due to an iatrogenic cause after PD, observed using CT imaging. Volumetry of pneumoperitoneum was performed using computer-aided image segmentation. To evaluate the clinical outcome, the paired t-test was performed to analyze the course of pain intensity on the numerical pain rating scale (NPRS, 0-10). Patient records were reviewed to determine PD-related adverse events and median drain duration.

RESULTS

The median pneumoperitoneum volume was 891.1 (127.7-3,677.0) mL. All PD procedures were successfully performed, with symptom relief and immediate abdominal decompression (mean segmental volume reduction, 79.8% ± 13.5). Acute abdomen symptoms were resolved, with significant improvement in pain intensity between the day of the PD procedure and the first day after the procdure (mean NPRS scores, 3.3 ± 1.9 vs 0.8 ± 1.0; P < .001). The median drain duration was 2 (1-3) days. No PD-associated adverse events were observed. After PD, 14 patients required only conservative management, whereas 2 patients with anastomotic leakage required additional surgery as they showed signs of persisting sepsis and generalized peritonitis.

CONCLUSIONS

PD is a safe and suitable procedure for the management of symptoms in patients with iatrogenic pneumoperitoneum presenting as acute abdomen.

Tension pneumoperitoneum caused by blunt trauma

Tension pneumoperitoneum (TPP), the accumulation of free intraabdominal air under pressure, is a rare event. TPP usually occurs from bowel surgery or bowel perforations. Less commonly, TPP occurs in the presence of pneumothoraces or during positive pressure ventilation. Trauma has rarely been a reported cause of TPP. The cases of 2 patients with TPP after blunt trauma are reported. The pathophysiology and management of TPP are discussed.

Tension pneumoperitoneum

Tension pneumoperitoneum developing in a middle aged asthmatic male during resuscitation after a respiratory arrest is reported. This was associated with bilateral tension pneumothorax and caused severe respiratory embarrassment which was relieved by needle decompression, after decompression of the pneumothoraces. The chest is not the only body cavity that can contain air under tension.

Tension pneumoperitoneum after heart-lung transplantation

Tension pneumoperitoneum is a medical emergency. We report 2 cases in which tension pneumoperitoneum occurred after heart-lung transplantation and was related to positive-pressure ventilation and a transdiaphragmatic passage of omentum used to wrap the airway anastomosis. Management in these patients was targeted toward decompression of intraperitoneal air with percutaneous needle or tube placement without exploratory laparotomy, and tube thoracostomy for the concomitant pneumothorax.

Acute intestinal pseudo-obstruction (Ogilvie's syndrome) complicating radical retropubic prostatectomy

We report 3 cases of acute colonic pseudo-obstruction in the immediate post-radical retropubic prostatectomy patient. We have not found this syndrome reported in this clinical setting, and suggest that it results from an imbalance in the autonomic innervation of the distal colon secondary to noxious afferent parasympathetic stimulation from the region of the prostate gland. Treatment guidelines are summarized stressing early recognition and conservative management of this potentially fatal complication.