Non-surgical pneumoperitoneum in the newborn infant

Tension pneumoperitoneum caused by rupture of intraabdominal soft tissue emphysema in a child supported with high-frequency oscillatory ventilation: a case report

Background

We reported a case with tension pneumoperitoneum while being on high-frequency oscillatory ventilation.

Case presentation

A 12-month-old Thai girl presented with acute respiratory distress syndrome, septic shock, and bacterial pneumonia. Although supported with mechanical ventilation, she still had severe hypoxia. She was then transitioned to high-frequency oscillatory ventilation. During a weaning period on day 7, she developed left tension pneumothorax requiring intercostal drainage and a markedly large amount of pneumoperitoneum. In spite of a bedside abdominocentesis, her abdomen was still tense and her hemodynamics was unstable. Subsequently, to exclude hollow viscus perforation, diaphragmatic injury caused by intercostal drainage, or abdominal compartment syndrome, she was transferred for surgery. There was no intestinal perforation. Postoperatively, she was on oxygen therapy, on chest physical therapy, and kept hemodynamically stable until she had recovered.

Conclusion

A case of tension pneumoperitoneum probably caused by high-frequency oscillatory ventilation was reported. Awareness of this condition should be included in the differential diagnosis.

Idiopathic neonatal pneumoperitoneum with favorable outcome: A case report and review

Neonatal pneumoperitoneum is a surgical emergency indicative of gastrointestinal perforation that requires immediate treatment to prevent death. There have been non-surgical conditions secondary to neonatal pneumoperitoneum (e.g., mechanical ventilation, pulmonary diseases and pneumatosis cystoides intestinalis) that neonates were able to overcome without the need for abdominal exploration. Idiopathic pneumoperitoneum, although similar to perforation of the alimentary tract and the previously mentioned non-surgical conditions, is a more rare and benign condition that does not yet have a definite cause. Hence, inexperienced surgeons may have a difficult time providing the right treatment for idiopathic pneumoperitoneum. We report a case of a neonate with a massive pneumoperitoneum who obtained a favorable outcome without surgical intervention. Nonetheless, the cause of pneumoperitoneum remains unclear. We hypothesize that the right sized perforation (range: 2 mm to 4 mm in diameter) at the anterior wall of the stomach is needed for pneumoperitoneum to occur. As the baby cries (aerophagia), the air in the stomach accumulates until it can enter the intraperitoneal cavity through the leak compressed by gastric peristalsis, hence forming a large pneumoperitoneum. Small amounts of gastric juice are able to penetrate the gastric wall; therefore, no signs or symptoms of peritonitis occur. The gastric leak self-seals, preventing further passage of the air, allowing the intraperitoneal free gas to dissipate gradually. This case demonstrated that laparotomy can be avoided in neonates with idiopathic pneumoperitoneum if a timely diagnosis is established.