Spontaneous idiopathic pneumoperitoneum with acute abdomen

Abstract

Pneumoperitoneum is often caused by visceral perforation, and usually manifests with symptoms of peritonitis requiring surgical intervention. Non-surgical spontaneous pneumoperitoneum (ie. not associated with organ perforation) is a rare entity due to intrathoracic, intra-abdominal, gynecologic, iatrogenic or other reasons, and is usually treated conservatively. Idiopathic spontaneous pneumoperitoneum is even rarer than visceral perforation or other causes of free intra-abdominal air. In this report, we present a case of idiopathic spontaneous pneumoperitoneum. A seventy-five-year-old female patient presented with acute abdominal pain, low-grade fever, and nausea. Her abdominal examination findings were vague, and she did not have leukocytosis. Free intra-abdominal air was detected on plain X-ray, she was followed-up with cessation of oral intake, nasogastric tube, fluid resuscitation and prophylactic antibiotics for one day. There were no signs of acute abdomen except diffuse abdominal tenderness by deep palpation on the first day examination. There was a mild leukocytosis with a shift to the left in leukocytes, and pneumoperitoneum on abdominal X-ray. The abdominal computed tomography revealed free intra-abdominal air and minimal free fluid in Douglas pouch. Her past medical history revealed cholecystectomy (10 years ago) with no chronic diseases, regular medications, smoking, or alcohol consumption. The patient underwent emergency laparotomy. Despite lack of an identifiable cause and uncertainty of etiology, the patient was discharged on postoperative day 5. A thorough medical history, appropriate laboratory tests and radiological techniques and physical examination should be combined for identification of patients with non-surgical pneumoperitoneum, and avoid unnecessary laparotomy, while minimally invasive techniques such as laparoscopy should be considered as part of evaluation.

Spontaneous pneumoperitoneum with duodenal diverticulosis in an elderly patient: a case report

“…If abdominal pain and distension are minimal, and peritoneal signs, fever, and leukocytosis are absent, conservative management should be considered for nonsurgical pneumoperitoneum [12]. However, spontaneous pneumoperitoneum poses significant management dilemmas for surgeons, especially when peritoneal signs are present [13,14]. Although Tani et al suggested that conservative treatment may be applicable for spontaneous pneumoperitoneum with peritoneal signs, exploratory laparotomy should be considered when signs and symptoms of peritonitis are present [15].…”

The clinical dilemma of the persistent idiopathic pneumoperitoneum: A case report

“…Intra-thoracic causes include thoracic trauma (such as barotrauma), post-cardio-pulmonary resuscitation and excessive mechanical ventilation with high peak inspiratory pressures [7,8]. In these cases, pneumoperitoneum is usually a result of raised intra-thoracic pressure, which leads to the leakage of intrathoracic air through microscopic pleural and diaphragmatic defects, and pneumomediastinum often co-exists [2]. In such cases, management of pneumoperitoneum is typically conservative [7,8].…”

“…Idiopathic pneumopertoneum (IP) is a rare clinical entity [[1], [2], [3], [4], [5]]. In over 90% of cases, pneumoperitoneum is due to hollow viscus perforation, usually requiring urgent surgical intervention [1,6].…”

“…The remaining 10% of cases are due to non-surgical entities that include various iatrogenic, intra-thoracic, and gynecological causes [[5], [6], [7]]. Rarely, when no cause can be identified, the patient is considered to have an IP [1,2,5]. The pathophysiology of IP is poorly understood and is largely regarded a diagnosis of exclusion [2].…”

“…Rarely, when no cause can be identified, the patient is considered to have an IP [1,2,5]. The pathophysiology of IP is poorly understood and is largely regarded a diagnosis of exclusion [2]. This group of patients require close attention to recognise those who can be safely managed conservatively, thereby avoiding unnecessary surgical intervention [1,8,9].…”