Unexpected Pneumoperitoneum: A Case Report

Background:Pneumoperitoneum is usually the result of visceral perforation requiring urgent surgical repair. In rarer cases, no perforation is found despite the present of free intra-peritoneal air. This is otherwise known as “spontaneous pneumoperitoneum”.Case presentation:We present a case of an 18-year old male who had upper abdominal pain but who otherwise was not peritonitic and had normal blood results. He was concerned about the cause of the pain as he had previously had an admission to a different hospital with similar symptoms. A chest x-ray revealed unexpected pneumoperitoneum. Subsequent imaging revealed no identifiable perforation and the patient was managed without proceeding to an emergency laparotomy. Conclusion:This case demonstrates the importance of considering an erect chest x-ray in patients presenting with upper abdominal pain, with otherwise normal parameters, to avoid missing rarer diagnoses. Furthermore it demonstrates how such cases of spontaneous pneumoperitoneum can be managed conservatively, avoiding unnecessary surgery.

796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis

Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI. We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.

Spontaneous pneumoperitoneum secondary to intestinal pneumatosis: an uncommon cause of acute abdomen

Intestinal pneumatosis is a rare entity characterized by gas accumulation in the submucosa and or subserosa of the intestinal tract wall and is generally associated with other diseases, the primary presentation is rare. Most of the cases are asymptomatic, being infrequent the presentation as an acute abdomen secondary to a spontaneous pneumoperitoneum. We report the case of a patient with systemic sclerosis, who presented to the emergency department with abdominal pain and intestinal obstruction, without improvement to conservative treatment and with progression to acute abdomen, for which surgical treatment was performed showing intestinal pneumatosis that compromised the entire small intestine.

Spontaneous pneumoperitoneum: Discerning from radiological imaging

Background: Pneumoperitoneum without any gastrointestinal (GI) perforation or peritonitis is entitled spontaneous pneumoperitoneum. We aimed to describe a radiological perspective in spontaneous pneumoperitoneum. Methods: This case series presented data of 4 cases of spontaneous pneumoperitoneum managed at our institution. Results: There were 85 patients with a provisional diagnosis of necrotizing enterocolitis (NEC) and/or pneumoperitoneum. Out of these, there were 4 patients with the final diagnosis of spontaneous pneumoperitoneum; three males and 1 female. At presentation, respiratory distress was seen in 3. It was preceded by mechanical ventilation in 3 patients. All 4 had soft abdominal distension, absence of features suggestive of peritonitis, and the presence of free air with an absence of air-fluid level in peritoneal cavity on erect abdominal radiographs. The Rigler sign was present in 3 patients. Abdominocentesis followed by abdominal drain placement was performed in 2 patients. Laparotomy was performed in 1 patient which could not point to any pathology (negative). An unfavorable outcome was seen in one patient with associated esophageal atresia. No patient had any evidence (either ultrasound/radiological or on laparotomy) of leakage of contents from the GI tract. Conclusions: In infants, especially preterm neonates, presenting with soft abdominal distension with abrupt onset of pneumoperitoneum, without clinical features of peritonitis and preceded by mechanical ventilation, diagnosis of spontaneous pneumoperitoneum should be considered.