Pneumoperitoneum without peritonitis

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.

Benign pneumoperitoneum in a neonate receiving positive pressure ventilation: A case report and clinical insights

The presence of air in the peritoneal cavity demonstrated radiographically as the crescent of air under the diaphragm is termed pneumoperitoneum. The causative agents may be divided into spontaneous, traumatic, iatrogenic, and miscellaneous. The majority (∼ 90%) of cases are attributed to hollow viscus perforation which requires immediate surgical attention. Neonatal pneumoperitoneum is a surgical emergency unless proven otherwise. A distinct entity termed benign pneumoperitoneum occurs in the absence of clinical and paraclinical features of peritonitis. Benign pneumoperitoneum may be caused by various thoracic, abdominal, and gynecological conditions. In neonates with respiratory distress pneumoperitoneum is a frequent association especially when treated with mechanical ventilation. The air leak phenomenon leads to air tracking from the ruptured alveoli along the interstitium to the mediastinum then to the retroperitoneum and ultimately into the peritoneal cavity. Such patients usually do not require surgical intervention and are managed conservatively. Knowledge of the existence of benign pneumoperitoneum helps to avoid unnecessary surgery thereby reducing operative morbidity and mortality.

A case of spontaneous idiopathic tension pneumoperitoneum successfully managed with bedside pig-tail catheter

We present a 67-year-old gentleman with a high perioperative mortality and morbidity risk who presented with spontaneous idiopathic tension pneumoperitoneum that was successfully managed with bedside pig-tail catheter insertion. Here we also discuss other potential non-surgical aetiologies of pneumoperitoneum.

The enigma of asymptomatic idiopathic pneumoperitoneum: A dangerous trap for general surgeons

INTRODUCTION

Idiopathic pneumoperitoneum is an extremely rare condition that can easily be misdiagnosed as an acute abdomen. Awareness of this phenomenon can help avoid unnecessary surgical intervention and the potential associated morbidities.

PRESENTATION OF CASE

A 76 year old man presented to hospital with dyspnoea and productive cough and was diagnosed with an infective exacerbation of COPD. He subsequently had a CTPA which showed a significant amount of free intraperitoneal gas in the upper abdomen. He was completely asymptomatic from this with no abdominal pain, distension, or significant rise in inflammatory markers. Of note, he had never had previous abdominal surgery or endoscopic procedures. He showed no signs of peritonism and was closely observed with serial abdominal examinations for 24 h. He subsequently tolerated oral intake and was discharged 8 days after admission.

DISCUSSION

Spontaneous pneumoperitoneum can be due to a variety of intrathoracic, gynaecologic, intra-abdominal and iatrogenic causes. This is a rare case of asymptomatic idiopathic pneumoperitoneum where no clear aetiology or risk factors were found for his free intraperitoneal gas. To the best of our knowledge there have only been two published case reports in the English literature describing idiopathic pneumoperitoneum in a patient that was completely asymptomatic from it.

CONCLUSION

As a general surgeon it is important to be aware of the non-surgical causes of pneumoperitoneum. Knowledge of this uncommon condition may help reduce the risk of unnecessary laparotomy.

Traumatic Pneumoperitoneum After Vaginal Intercourse

OBJECTIVES

Pneumoperitoneum with peritonitis, although uncommon, is a serious injury encountered in the pediatric emergency department. Although the patients may often appear ill or toxic, they can have normal vital signs at initial presentation. Patients with such injury can present with a variety of complaints because of the nature of referred pain. As a result, some patients may be more or less straightforward, thus illustrating the importance of obtaining a detailed history and performing a thorough physical examination.

METHODS

We discuss an uncommon case report of pneumoperitoneum with peritonitis in an adolescent patient presenting with vaginal bleeding and abdominal pain hours after vigorous coitus.

RESULTS

Examination under anesthesia, flexible sigmoidoscopy, and exploratory laparoscopy revealed a vaginal laceration and a 2- to 3-cm perforated area at the left edge of the vaginal laceration that involved the rectovaginal septum entering the peritoneal cavity.

CONCLUSIONS

Pneumoperitoneum resulting from vaginal intercourse in an otherwise healthy adolescent female is a rare cause of peritonitis. Although it has been described in the adult literature, this case illustrates the importance of considering sexual history as a contributory factor in pediatric patients presenting with an acute abdomen.

Asymptomatic pneumoperitoneum in pneumatosis coli: A misleading operative indication

INTRODUCTION

Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum.

PRESENTATION OF CASE

A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present.

DISCUSSION

Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock.

CONCLUSIONS

We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient's conditions and unclear origin of the sepsis.

Pneumatosis Cystoides Intestinalis - A Review

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Idiopatic and secondary forms of the disease can be distinguished. There are presented several theories explaining pneumatogenesis in this article. The specific and non-specific symptoms are described. Attention is drawn to the pneumoperitoneum without signs of peritoneal irritation, what is a typical complication of this disease. The suspition of pneumatosis cystoides intestinalis may be based on plain abdominal X-ray, and is usually confirmed by computer tomography or magnetic resonance imaging. The therapy can be conservative or surgical. In conclusion, although pneumatosis cystoides intestinalis is a rare disease, it may represent a problem in differential diagnosis of abdominal pain.

Pneumatosis Intestinalis and Intestinal Perforation in a Patient Receiving Tocilizumab

In this article, we report a case of pneumatosis intestinalis associated with tocilizumab use. This is a unique case and may explain the increased rate of idiopathic bowel perforation among patients taking tocilizumab.

Free air on CT and the risk of peritonitis in peritoneal dialysis patients: a retrospective study

BACKGROUND

Intra-abdominal free air is found frequently in patients undergoing peritoneal dialysis (PD). Some studies have investigated an association between intra-abdominal free air and peritonitis in PD patients. However, most used chest X-rays, which are of limited sensitivity, and the association was not made clear. We conducted a retrospective study of the association between peritonitis and intra-abdominal free air using computed tomography.

METHODS

The presence and volume of free air, and its relationship with other variables, were assessed on review of routine examinations in 108 patients. Correlations between the presence of free air and age, duration of PD, continuous ambulatory versus automated PD, presence or absence of a person who assisted in bag changes, exit-site infection, tunnel infection and peritonitis were assessed.

RESULTS

Free air was detected in 29 patients (27.1%). The prevalence of peritonitis was higher in the free air (+) group than in the free air (-) group: 1/40.2 patient-months for free air (+) versus 1/96.9 patient-months for free air (-). The risk ratio of free air for peritonitis was 2.41 (95% confidence interval: 2.28-2.55) and was similar when corrected for age, gender, albumin, diabetes mellitus and body mass index.

CONCLUSION

Free air is an independent risk factor for peritonitis in PD patients. This suggests that bag change procedures should be re-evaluated, and patients re-educated, when necessary.

Non-surgical pneumoperitoneum after oro-genital intercourse

INTRODUCTION

In many cases, a pneumoperitoneum is due to air escaping from a perforated hollow viscus or surgical intervention but there are increasing reports of non-surgical causes.

PRESENTATION OF CASE

We report a case where a pneumoperitoneum was identified after oro-genital sexual intercourse.

DISCUSSION

There were nineteen reported cases of non-surgical pneumoperitoneum from gynaecologic causes up to May 2013. We report an additional case four hours after oro-genital intercourse. Close clinical observation and symptomatic treatment are usually all that is required but operative interventions should be considered if the patient develops abdominal pain, peritoneal signs, fever or leukocytosis during observation.

CONCLUSION

This adds to the world literature on non-surgical pneumoperitoneum from oro-genital intercourse. Clinicians should be aware of this condition and focus on medical-sexual history as this information could prevent a patient from being exposed to expensive diagnostics and invasive operative treatments. Patients should also be educated about the mechanisms to avoid future possible diagnostic dilemmas.

Nonsurgical pneumoperitoneum in a dog secondary to blunt force trauma to the chest

OBJECTIVE

To describe the medical management of pneumoperitoneum without surgical intervention in a dog that sustained blunt force trauma to the thorax. To review the mechanisms of how a thoracic injury (ie, extra-abdominal source) can lead to pneumoperitoneum.

CASE SUMMARY

A 4-month-old Shih Tzu puppy was attacked by a larger dog and sustained various injuries including a pneumothorax, pneumomediastinum, and a pneumoperitoneum. The dog presented minimally responsive and in respiratory distress secondary to pulmonary contusions and noncardiogenic pulmonary edema. No penetrating wounds to the abdomen or thorax were identified. As no immediate surgical lesion was identified the dog was treated conservatively without the need for surgical intervention. The dog was successfully managed and discharged after a few days of supportive care with oxygen therapy. Before discharge, repeat radiographs revealed complete resolution of the pneumothorax, pneumomediastinum, and pneumoperitoneum.

NEW OR UNIQUE INFORMATION PROVIDED

Cases of nonsurgical pneumoperitoneum have rarely been reported in the veterinary literature. A thoracic source of pneumoperitoneum should be considered when the suspicion of a ruptured viscus is low based on diagnostic procedures (eg, ultrasound, computed tomography, and diagnostic peritoneal lavage), in addition to physical examination (eg, lack of fever and absence of abdominal pain) and laboratory findings (eg, absence of inflammatory leukogram).

Dysplasia in perforated intestinal pneumatosis complicating a previous jejuno-ileal bypass: A cautionary note

We present the case of an elderly woman who developed a bowel perforation related to pneumatosis intestinalis, 33 years after a jejuno-ileal bypass for severe obesity. Final histological examination revealed the presence of dysplasia in the resected specimen. On the basis of our case and a review of the literature, we discuss the etiopathogenesis, the clinical aspects and the treatment of this rare condition.

Jacuzzi jet-induced pneumoperitoneum

Pneumoperitoneum outside the setting of recent surgical intervention usually indicates perforation of the gastrointestinal tract. Following radiologic evidence of pneumoperitoneum, surgical exploration of the abdomen may be indicated depending on the nature of the patient's presentation. We present the radiological findings of a healthy young woman who presented with acute onset of abdominal pain and was found to have extensive pneumoperitoneum. No visceral disruption was evident by multidetector CT or by single-contrast barium fluoroscopic evaluation of the upper gastrointestinal tract. Knowledge of benign causes of pneumoperitoneum by the radiologist may avert an unnecessary laparotomy.

Pneumoperitoneum: a review of nonsurgical causes

OBJECTIVE

To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate.

DATA SOURCE

We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications.

STUDY SELECTION

We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy.

DATA SYNTHESIS

Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

CONCLUSIONS

Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Nonsurgical causes of pneumoperitoneum

The radiographic manifestation of free air in the peritoneal cavity suggests serious intra-abdominal disease and the need for urgent surgical management. Yet, about 10% of all cases of pneumoperitoneum are caused by physiologic processes that do not require surgical management. We retrospectively reviewed cases of nonsurgical causes of pneumoperitoneum at the 2 teaching hospitals of a university medical center between January 1990 and December 1995. Successful management by observation and supportive care without surgical intervention was defined as the diagnostic feature of nonperforation. Failure of a laparotomy to delineate a surgical cause or to result in a reparative procedure is congruent with a nonsurgical cause of pneumoperitoneum. During this period, 8 patients (6 men and 2 women; mean age, 61 years) were identified with nonsurgical causes of pneumoperitoneum. Two patients underwent negative laparotomy, and the other 6 were successfully managed nonoperatively and discharged from the hospital. In 6 patients, a cause of the pneumoperitoneum was identified. The causes may be grouped under the following categories: postoperatively retained air, thoracic, abdominal, gynecologic, and idiopathic. In our review of the literature, 61 of 139 reported cases underwent surgical treatment without evidence of perforated viscus. To avoid unnecessary surgical procedures, both primary medicine physicians and surgeons need to recognize nonsurgical causes of pneumoperitoneum. Conservative management is warranted in the absence of symptoms and signs of peritonitis.

Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas

Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

Pneumatosis intestinalis. Two case reports and a retrospective review of the literature from 1985 to 1995

Pneumatosis intestinalis (PI) is characterized by subserosal or submucosal gas-filled cysts of the gastrointestinal tract. The course may be benign or may lead to the need for urgent surgery. Knowledge of the differential diagnosis, course, and treatment modalities are key in providing optimal care to patients who present with this entity. In this article, two cases of "benign" pneumatosis seen at our institution over a one-month period are presented, along with a retrospective review of the English literature from January 1985 to March 1995. Incidence, symptoms, gross and microscopic appearance, radiographic appearance, etiology, differential diagnosis and therapy are reviewed.

Computed tomography in pneumatosis intestinalis: differential diagnosis and therapeutic consequences

Case reports of five patients with pneumatosis intestinalis diagnosed by computed tomography (CT) are presented. Etiology, differential diagnoses, and clinical consequences arising from CT imaging are discussed. In four of the patients, pneumatosis was found to be secondary to gastric ulcer, colon carcinoma, metastasis in the mesentery, and trauma-induced mesenteric ischemia. In one patient, the etiology remained elusive. Using CT, both the extent and the distribution pattern of pneumatosis could be depicted, allowing for differentiation of primary and secondary forms and assessment of prognosis. Evaluation with a lung window is a pre-requisite for reliable diagnosis of pneumatosis with CT. The presence of gas in the mesenteric or portal venous system in mesenteric ischemia is indicative of an unfavorable prognosis.

Significance of intra-abdominal extraluminal air detected by CT scan in blunt abdominal trauma

The purpose of this study was to determine the frequency and significance of computed tomographic (CT) scan-detected pneumoperitoneum in blunt abdominal trauma. We retrospectively reviewed 118 consecutive CT scans of the abdomen in blunt abdominal trauma patients (mean Injury Severity Score 24), performed at our Regional Trauma Unit over a 12-month period. Seven (5.9%) patients had intra-abdominal extraluminal air. None of these seven patients had evidence of bowel perforation at laparotomy (two) or on clinical follow-up (five). All seven had chest tubes in place before the CT scan. None of the seven patients were on mechanical ventilation at the time of CT scan. In the setting of blunt abdominal trauma pneumoperitoneum does not necessarily indicate hollow viscus injury. It frequently is secondary to other etiologies, especially dissection of interstitial air from the chest, as suggested in this study. The decision for laparotomy should be based on a combination of the clinical findings, CT scan results, or other diagnostic tests such as peritoneal lavage.

Benign spontaneous pneumoperitoneum in an elderly patient treated medically with recovery

Images

Giant chest wall arteriovenous malformation with spinal cord compression

Images