Non-surgical Pneumoperitoneum in the Setting of Gram-negative Sepsis

Abstract

Pneumoperitoneum is described as the presence of free air in the peritoneal cavity. In the majority of cases, it is the manifestation of abdominal viscus perforation, requiring an emergent surgical exploration. In rare cases, however, no evidence of perforation of the gastrointestinal or genitourinary tracts can be found at exploration, and in such cases, the pneumoperitoneum is referred to as non-surgical pneumoperitoneum. We present a case of an 87-year-old man who developed a non-surgical pneumoperitoneum in the setting of gram-negative sepsis. The patient was admitted for treatment of obstructive uropathy and sepsis secondary to a gram-negative urinary tract infection. Despite the initial resuscitation and antibiotic therapy, his hospital course was complicated by worsening abdominal discomfort, and a chest radiograph revealed free air under the diaphragm. He was taken to the operating room for an emergent surgical exploration that revealed no visceral perforation or other possible surgical causes. He tolerated and recovered from surgery well, and had a complete resolution of pneumoperitoneum in the early post-surgery period, per radiographic imaging. This interesting case highlights a rare case of idiopathic nonsurgical pneumoperitoneum in the setting of gram-negative sepsis. Additionally, we discuss considering non-surgical etiologies for patients without clinical signs or surgical evidence of perforation.

A Rare Case of Spontaneous Idiopathic Pneumoperitoneum Presenting as Abdominal Pain

“…The complexities lie with patients with minimal symptomology and unclear sources. Patients can have a visceral perforation, but may appear to be stable [ 4 , 5 ]. These patients can be treated with either diagnostic laparoscopy/laparotomy or close observation.…”

Negative surgical exploration in suspected gastrointestinal perforation: trend, preoperative predictors, and etiologies

“…However, such a strategy will certainly raise the unnecessary surgical exploration rate and the morbidity. Most of the previous researches merely focused on reviewing the causes of nonsurgical pneumoperitoneum and numerous studies were case reports (12)(13)(14)(15)(16)(17).…”

Neumoperitoneo espontáneo no quirúrgico en paciente COVID-19 positivo con neumonía bilateral severa

“…Neumoperitoneo espontá neo no quirú rgico en paciente COVID-19 positivo con neumonía bilateral severa Non-surgical spontaneous pneumoperitoneum in a COVID-19 positive patient with severe bilateral pneumonia El neumoperitoneo espontá neo no quirú rgico supone el 10% de los casos descritos en la literatura [1][2][3][4][5][6][7][8] . Es una entidad de difícil diagnó stico, subsidiaria de un manejo conservador, con la consiguiente reducció n de iatrogenia 1,2,[4][5][6][7] .…”

“…El diagnó stico de neumoperitoneo espontá neo no quirú rgico es muy controvertido y supone un dilema para el cirujano, fundamentalmente cuando la sintomatología abdominal es dudosa. Por lo tanto, el diagnó stico de esta entidad requiere una adecuada valoració n clínica, radioló gica y analítica 1,4,7 . Se requiere que el paciente se encuentre asintomá tico desde el punto de vista abdominal o paucisintomá tico, junto con reactantes de fase aguda no elevados o en disminució n y pruebas radioló gicas que descarten una complicació n asociada.…”

“…Se requiere que el paciente se encuentre asintomá tico desde el punto de vista abdominal o paucisintomá tico, junto con reactantes de fase aguda no elevados o en disminució n y pruebas radioló gicas que descarten una complicació n asociada. Por ello, se recomienda realizar TC con contraste oral y rectal, con el objetivo de completar la informació n. En caso de existir incongruencia entre estas tres entidades, es recomendable realizar una laparotomía exploradora 1,2,7,9 .…”