A multifactorial biological modulation eliminates PNF, improves liver function and increases survival. Biochemically, TNF-alpha and redox-active iron are suppressed and biliary bile salt toxicity is reduced. Translating this strategy clinically may lead to wider and safer use of NHBD.

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.

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