Management of incidentally detected idiopathic pneumoperitoneum: A case report and literature review

Abstract

Introduction Pneumoperitoneum usually requires emergency surgery. Asymptomatic idiopathic pneumoperitoneum is a rare subgroup of pneumoperitoneum for which a management algorithm has not been established. Presentation of case In an 88-year-old female patient, pneumoperitoneum was found incidentally by chest computed tomography during a periodic follow-up for sarcoidosis. Emergency admission was ordered for conservative treatment. Upper gastrointestinal endoscopy revealed edematous mucosa in the entire gastric vestibule. After being discharged on the 7th day, her clinical course was uneventful over 2 months of follow-up. Discussion The initial clinical manifestations of pneumoperitoneum are variable and range widely from asymptomatic to septic shock. The etiology of pneumoperitoneum in our patient implied a subclinical visceral perforation that resolved without treatment. We advocate an algorithm for the initial management of pneumoperitoneum according to the extent of peritonitis and impaired conditions. Conclusion Incidentally found asymptomatic pneumoperitoneum does not always require intervention. Careful and repeated physical assessment with investigation of underlying etiology is important in the management of pneumoperitoneum.

Navigating Asymptomatic Idiopathic Pneumoperitoneum: A Case Report and a Literature Review

“…This diverse symptomatology renders the preposition for a standard treatment protocol for pneumoperitoneum based on clinical presentation hard to conceive. Sakaguchi et al proposed an algorithm in 2021 [12] for the initial management of pneumoperitoneum, considering specific symptoms such as peritonitis, ascites, and sepsis. The algorithm entails an escalation of management options ranging from 'careful follow-up' to the 'operating room.'…”

Idiopathic pneumoperitoneum in a single case: an unusual entity

“…IP is quite rare and to the best of our knowledge not adequately reported in the literature. In cases where pneumoperitoneum is nonsurgical or idiopathic, there has been unnecessary explorative laparotomies, typically causing more harm than benefits [ 1 , 5 ]. The current literature suggests if a patient does not have any peritoneal symptoms and if imaging examinations show absence of abdominal cavity pathology, then, clinicians may consider spontaneous pneumoperitoneum, which does not require surgical intervention [ 4 ].…”

“…The etiology and clinical manifestations vary per individuals, and in about 90% of cases associated with visceral perforation are linked with gastric and duodenal ulcer. The other 10% of cases, broadly described as idiopathic pneumoperitoneum (IP) have no direct connection with a demonstrable risk factor [ 1 , 2 ].…”

Pneumoperitoneum: always a surgical case?

“…Experience shows that diagnostic laparoscopy can be beneficial to such patients especially facing generalized peritonitis. It has been shown that patients admitted with moderate symptoms and no signs of infection can be primarily observed and have a better course if a conservative line of treatment is followed [ 8 , 9 ]. In patients with risk factors for perforation of hollow organs, it is important to exclude such a complication, which can also be done by endoscopy if the patient’s condition permits [ 5 , 8 , 9 ].…”