[Spontaneous idiopathic pneumoperitoneum in a patient with COVID-19]

The authors present a patient with COVID-19 and spontaneous idiopathic pneumoperitoneum. A 77-year-old man suffering from coronary artery disease, diabetes mellitus and cognitive disorders was diagnosed with bilateral pneumonia and COVID-19. Oxygen support through a face mask was prescribed. After 21 days, oxygen saturation decrease and mild abdominal symptoms required CT-based examination. Pneumoperitoneum without pneumothorax and pneumomediastinum was revealed. Explorative laparotomy found no abdominal diseases. According to the literature, spontaneous pneumoperitoneum in patients with COVID-19 is usually associated with high pressure oxygen therapy, but not always associated with intrathoracic complications. Conservative treatment may be appropriate in patients with spontaneous pneumoperitoneum, but any unclear findings can require surgery.

Pneumopéritoine spontané idiopathique: à propos d’une observation

Le pneumopéritoine résulte, dans la majorité des cas, d'une perforation du tractus gastro-intestinal dont le traitement est habituellement chirurgical. Son caractère spontané est rare, avec dans ce cas, une présentation inhabituelle qui met le chirurgien devant un dilemme diagnostic et thérapeutique. Nous rapportons un cas de pneumopéritoine spontané chez un sujet de 77 ans ayant bien évolué sous traitement non opératoire. Nous discutons des modalités de prise en charge de cette entité peu commune.

[Low-pressure pneumoperitoneum with abdominal elevation in laparoscopic radical prosta-tectomy in elderly patients with a localized form of prostate cancer.]

Prostate cancer is an actual problem among males of older age groups, while the concomi-tant premorbid background of this category of patients often leads to the development of postopera-tive complications using the standard surgical method. The article presents the results of using low-pressure pneumoperitoneum with anterior abdominal wall lifting for laparoscopic radical prostatec-tomy in elderly patients with a localized form of prostate cancer. Convincingly shown that the use of low-pressure techniques pneumoperitoneum with lifting anterior abdominal wall ensures satis-factory operating field, obtains stable indicators of operational monitoring and allow to reduce the duration of the operation, as well as reduce the duration of hospitalization and incidence of postoperative complications.

Analysis of the use of upright abdominal radiography for evaluating intestinal perforations in handlebar traumas: Three case reports

RATIONALE

Intestinal perforations due to blunt abdominal handlebar trauma are difficult to diagnose. This report presents a retrospective analysis of 3 patients with intestinal perforations due to abdominal bicycle handlebar trauma who were diagnosed via upright abdominal radiography.

PATIENTS CONCERNS

All the patients lost their balance while riding a bicycle for leisure and had fallen on the handlebar tip. The patients were initially misdiagnosed at different-level health centers despite various radiologic investigations performed.

DIAGNOSIS

The patients' intestinal perforations were diagnosed via plain upright abdominal X-ray radiography (UAXR) in our institution.

INTERVENTIONS AND OUTCOMES

The children underwent exploratory laparotomy due to intestinal perforations. All the perforations were repaired either with primary closure or bowel resection and anastomosis with successful outcomes.

LESSONS

Pneumoperitoneum due to intestinal perforation can be diagnosed via UAXR with appropriate patient positioning and timing. This case series shows that to accurately diagnose intestinal perforations, upright plain X-ray should be routinely performed, carefully evaluated, and repeated in patients with enduring abdominal complaints.

[Abdominal pain and fever with urinary symptoms]

A man consults for abdominal pain and fever. The diagnosis is suspected on a plain abdominal radiograph.

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.

[Pneumoperitoneum after cardiac surgery. A complete anamnesis is the clue]

Herein we present the case of an 82 year-old patient undergoing cardiac surgery for mitral valve replacement. Fifteen years earlier, the patient had undergone surgery to replace his aortic valve, so that it was now a cardiac reoperation. Through sternotomy, and release of pericardial adherences, there was an accidental opening of a small portion of the peritoneum, proceeding to repair with simple suture. Postoperatively, the presence of pneumoperitoneum alarmed about the possibility of an intra-abdominal complication but it was subsequently discarded with recent surgical process. Through this article we review what the pneumoperitoneum consist, its causes and management, as well as highlighting possible etiologies sometimes not considered as a recent cardiac surgery, simply because the patient in found in different contexts and we do not think about those possibilities.

A Rare Case of Benign Pneumatosis Intestinalis with Portal Venous Gas and Pneumoperitoneum Induced by Acarbose

Alpha glucosidase inhibitors have been shown to be associated with pneumatosis intestinalis (PI) in recent reports. We herein report the case of a 73-year old man who received treatment with an alpha glucosidase inhibitor (acarbose) and presented with acute abdomen. A computed tomography scan demonstrated PI in addition to intrahepatic portal air and pneumoperitoneum. During exploratory laparotomy, we found no evidence of hollow organ perforation or bowel necrosis. The patient recovered after conservative treatment with cessation of the alpha glucosidase inhibitor. This is the first report to describe the combination of PI with portal venous gas and pneumoperitoneum caused by an alpha-glucosidase inhibitor.

Pneumoperitoneum after virtual colonoscopy: causes, risk factors, and management

Computed tomographic virtual colonoscopy (CTVC) is a safe and minimally invasive modality when compared with fiberoptic colonoscopy for evaluating the colon and rectum. We have reviewed the risks for colonic perforation by investigating the relevant literature. The objectives of this study were to assess the risk of colonic perforation during CTVC, describe risk factors, evaluate ways to reduce the incidence complications, and to review management and treatment options. A formal search of indexed publications was performed through PubMed. Search queries using keywords "CT colonography," "CT virtual colonoscopy," "virtual colonoscopy," and "perforation" yielded a total of 133 articles. A total of eight case reports and four review articles were selected. Combining case reports and review articles, a total of 25 cases of colonic perforation after CTVC have been reported. Causes include, but are not limited to, diverticular disease, irritable bowel diseases, obstructive processes, malignancies, and iatrogenic injury. Both operative and nonoperative management has been described. Nonoperative management has been proven safe and successful in minimally symptomatic and stable patients. Colonic perforation after CTVC is a rare complication and very few cases have been reported. Several risk factors are recurrent in the literature and must be acknowledged at the time of the study. Management options vary and should be tailored to each individual patient.

[Imaging assessment of neonatal necrotizing enterocolitis]

OBJECTIVE

To improve the understanding of recognizing and diagnosis of neonatal necrotizing enterocolitis (NEC), imaging assessment of neonates with NEC was analyzed retrospectively.

METHOD

Data of 211 cases of NEC were retrospectively collected from the Department of Neonatology, Children's Hospital of Chongqing Medical University between Jan.1(st) 2006-Dec.31(st) 2011.

RESULT

Analysis of abdominal X-ray of 211 cases showed that there were 40 cases (19.0%) who had no changes on each X-ray, 47 cases (22.3%) had improvement and 23 cases (10.9%) became worse. In the group of no changes, positive rate with good prognosis was 97.5% and with poor prognosis, it was 2.5%. In the group of improvement, positive rate with good prognosis was 97.9%, and the contrary was 2.1%. Positive rate with good prognosis was 56.5%, and the contrary was 43.5% in worse group. Chi-square analysis of the three groups showed χ(2) = 31.742, P < 0.01. Comparison of detection rate of pneumoperitoneum on abdominal X-ray (16.0%, 12/75) and Doppler US (1.3%, 1/75), χ(2) = 10.191, P < 0.05, portal pneumatosis on abdominal X-ray(1.3%, 1/75) versus Doppler US (12.0%,9/75), χ(2) = 6.857, P < 0.05. Surgical timing mostly corresponded to pneumoperitoneum (OR = 19.543) and intestinal obstruction (OR = 19.527) of abdominal X-ray. The logistic regression equation is y = -2.915-1.588x1+2.972x4+2.973x7 + 1.711x9 (χ(2) = 101.705, P < 0.01).

CONCLUSION

Abdominal X-ray is the most important method of diagnosis of NEC, the group of deterioration of abdominal X-ray has obvious bad prognosis differ from no change group and better group. Comparison with abdominal X-ray and Doppler US, the former in pneumoperitoneum positive rate was higher than the latter, at the same time, portal pneumatosis on Doppler US is more sensitive to abdominal X-ray, the value of two imaging assessments both supplement each other. Surgical timing mostly corresponds to pneumoperitoneum and intestinal obstruction.

A clinical perspective of necrotizing enterocolitis: past, present, and future

Necrotizing enterocolitis (NEC) primarily affects premature infants. It is less common in term and late preterm infants. The age of onset is inversely related to the postmenstrual age at birth. In term infants, NEC is commonly associated with congenital heart diseases. NEC has also been associated with other anomalies. More than 85% of all NEC cases occur in very low birth weight infants or in very premature infants. Despite incremental advances in our understanding of the clinical presentation and pathophysiology of NEC, universal prevention of this disease continues to elude us even in the twenty-first century.

Tension pneumoperitoneum: a rare complication of upper gastrointestinal endoscopy

INTRODUCTION

Tension pneumoperitoneum is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure. Various iatrogenic procedures are responsible for this complication. We herein report a case of tension pneumoperitoneum resulting from upper gastrointestinal endoscopy.

CASE DESCRIPTION

A 45-y-old man was referred to our department because of melena. Esophagogastroscopy was unsuccessful because of failure to inflate the stomach, and sudden abdominal distension was noted immediately after the procedure. The hemodynamic status of the patient was compromised, and the imminent collapse was prevented with emergent needle paracentesis. Decompression of the abdominal cavity restored vital signs to normal allowing definitive surgical treatment.

DISCUSSION

Upper gastrointestinal endoscopy is a rare cause of this life-threatening complication. The combination of acute abdominal distension with hemodynamic instability following endoscopic procedures should raise suspicion of tension pneumoperitoneum. Needle decompression is life-saving and should be performed instantly upon recognition of this condition.

[Pneumoperitoneum, pneumoretroperitoneum, bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema due ERCP]

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential procedure in the diagnosis and treatment of biliopancreatic diseases. Complications of this procedure are potentially serious, being necessary to know how to recognize them for the application of the appropriate treatment. We report the case of a 79-year-old woman who developed a massive subcutaneous emphysema, bilateral pneumothorax, retropneumomediastinum, retropneumoperitoneum and pneumoperitoneum due to iatrogenic duodenal injury secondary to ERCP. The clinical suspicion for early diagnosis of iatrogenic injury after ERCP will determine the correct treatment of this complication and will achieve better outcomes.

[Tension pneumoperitoneum as a complication of endoscopic ultrasound guided transgastric drainage of pancreatic pseudocyst: case report and review of the literature]

Pancreatic pseudocyst develops as a complication in some cases of pancreatitis. Endoscopic drainage is one of the available therapies, but it has limitations when a visible compression over the gastric or duodenal wall is not present, or when portal hypertension exists. Endoscopic ultrasonography allows for a guided approach even in cases where external compression over the gastrointestinal tract is barely visible or non-existent, and it also helps to prevent vascular injury during puncture of the fluid collection. The most frequent early complications related to cystogastrostomy and cystoduodenostomy are bleeding and pneumoperitoneum, and late complications are stent migration or occlusion, and infection. We report the case of a patient who developed tense pneumoperitoneum immediately after endoscopic ultrasound guided drainage of a pancreatic pseudocyst, and was treated conservatively. This is a severe event, and can be managed by emergency decompression through paracentesis as first line therapy. Most cases of pneumoperitoneum can be managed without surgery,but close observation is mandatory in order to timely detect and treat conditions needing surgical intervention.

KEY WORDS

pancreatic.

[Free abdominal air in the emergency room--a diagnostic dilemma]

The current article revolves upon the challenge of diagnosing free peritoneal air in an abdominal X-ray. We present an 80 year old lady who was admitted due to abdominal pain and vomiting. On an acute abdomen XR series, a small amount of free air was suspected, but this was inconclusive. This article focuses upon the complexity of diagnosing abdominal free air Acute abdomen radiography is an essential tool in the evaluation of an acute abdomen, and research has shown that an acute abdominal X-ray series appropriately conducted and interpreted by qualified experts can show as little as 1 cc of free air in the peritoneum. Other studies, on the other hand, have shown that 30-50% of patients with bowel perforation, especially in the elderly population, will not show signs of free air on X-rays. We believe that the proper evaluation and diagnosis of free air involves a methodical approach. First one should begin with an acute abdominal X-ray series. It is advised to have the patient stand or lie in the left decubitus position for 10-15 minutes before the X-rays are conducted. Use of high resolution monitors to enhance the visual acuity and consulting an expert radiologist can help when in doubt. If one is still not sure, it is recommended to perform a CT scan, which is the gold standard for detecting free peritoneal air.

Pneumoperitoneum in association with perforated appendicitis in a Brazilian Amazon woman. Case report

Radiographic findings of free air in the peritoneal cavity secondary to perforation of a acutely inflamed appendix are extremely rare. It accounts for about 0-7% of all patients with pneumoperitoneum. We report on a 58-years-old Brazilian Amazon woman presenting a 1- week history of abdominal pain, tenderness and distension associated with asthenia and without passage of stool or gas. Abdominal percussion revealed a tympanic sound located on the right hypocondrium. Plain chest radiography revealed a large amount of free air beneath the right leaf of the diaphram. The patient was taken immediately to the operation room and, during surgery, a gangrenous appendix with an apex perforation was verified. Appendectomy was performed as routinely. The patient evolved with pneumonia and septic shock that responded well to intravenous antibiotics and vasoactive drugs. She was discharged to home on the twenty-first post-operative day in good clinical conditions. This case highlights that perforated acute appendicitis is rarely associated with pneumoperitoneum, but it must be considered in the differential diagnosis of patients presenting right abdominal pain and free intraperitoneal air.

A case of non-surgical pneumoperitonium: gas under the diaphragm

A 58-year-old woman presented with an unexpected episode of vomiting and an acute abdomen. The patient mentioned a vague history of decreased appetite dyspepsia and constipation. Abdominal X-Ray revealed gas under diaphragm. An Open laparotomy was carried out to evacuate the free gas trapped under the diaphragm. The condition is almost always associated with perforation of abdominal viscera and accumulation of air during surgical or gynaecological procedures or peritoneal dialysis. In the reported case, laparotomy revealed no sign of perforation in GIT, uterine fundus or fistulas and nor did the have patient have any history of surgical or gynaecological procedures. This lead to suggestion of spontaneous or non-surgical pneumoperitonium which is extremely rare. Extensive investigations revealed no known cause pneumoperitonium making our case rare and unique.

[A rare cause of pneumoperitoneum]

We provide the description of a 77 year old patient, admitted into the IC unit, with whom the surgical intervention was required by the presence of a massive pneumoperitoneum observed during abdominal CT. Anamnestic and clinical information was scarce; the patient had been admitted into the gastroenterology unit with the following diagnosis: acute pancreatitis, renal failure, atrioventricular block, while the hemodynamic instability made hospitalisation into the IC unit mandatory. Anatomopathological lesions secondary to a major vascular damage at the level of the celiac trunk and at the superior mesenteric level were noticed intraoperatively: total gastric necrosis with perforation, splenic infarction, entero-mesenteric infarction, abdominal wall necrosis. The patient did not allow for a surgical solution. The anatomopathological examination of the gastric tissue fragment enabled the diagnosis of extensive gangrene of the gastric wall. The relevance of the case consists in the presence of an abdominal vascular damage detected in full development, where the pneumoperitoneum required surgical exploration. The intricacy of the anatomopathological lesions accounts for the acute painful abdominal onset, accompanied by quick hemodynamic, clinical, and biochemical deterioration. Thus, gastric perforation through rupture secondary to total gastric gangrene of vascular origin joins the many causes of pneumoperitoneum.

The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases

Percutaneous endoscopic gastrostomy (PEG) is the procedure of choice for establishing enteral access in patients unable to take oral feedings. Serious complications are rare; however, misplaced PEGs and PEG/Jejunums can lead to hollow viscus injuries with intra-abdominal contamination and subsequent peritonitis, septicemia, and death. The presence of free intra-abdominal air is a reliable indicator of a perforated viscus and often points to a surgical emergency; however, in the case of PEGs, pneumoperitoneum without a perforated viscus, or "benign pneumoperitoneum" creates a diagnostic dilemma. To determine the incidence and clinical significance of pneumoperitoneum after PEG or PEG/Jejunum (J) we reviewed the records of 722 patients who underwent these procedures at our institution. Of 39 patients found to have free air after PEG/PEG/J placement, 33 (85%) had "benign pneumoperitoneum" and were discharged without complication or surgical intervention. Of the six patients with serious complications related to their procedure, five (83%) had clinical signs of intra-abdominal complications (peritonitis) that helped guide their management. Of these six patients, the two receiving abdominal radiographs instead of abdominal CT scanning had a 50 per cent negative laparotomy rate. We present an algorithm for the management of patients found to have pneumoperitoneum after PEG or PEG/J placement.