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LETTER TO THE EDITOR
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 60-61

Spontaneous pneumoperitoneum: A surgical dilemma


1 Department of General Surgery, KIMS, Narketpally, Nalgonda, Telangana, India
2 Department of Radiology, KIMS, Narketpally, Nalgonda, Telangana, India

Date of Web Publication16-Mar-2015

Correspondence Address:
Dr. Yerrarapu Srimanarayana
Department of General Surgery, KIMS, Narketpally, Nalgonda, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.153334

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How to cite this article:
Subramanyam M, Srimanarayana Y, Kumar TK, Krishna MH, Krishna V. Spontaneous pneumoperitoneum: A surgical dilemma. J NTR Univ Health Sci 2015;4:60-1

How to cite this URL:
Subramanyam M, Srimanarayana Y, Kumar TK, Krishna MH, Krishna V. Spontaneous pneumoperitoneum: A surgical dilemma. J NTR Univ Health Sci [serial online] 2015 [cited 2019 Aug 20];4:60-1. Available from: http://www.jdrntruhs.org/text.asp?2015/4/1/60/153334

Sir,

Pneumoperitoneum is caused by perforation of hollow viscera (90%), with perforated peptic ulcer being common. In rare cases, the cause may be extra-abdominal and idiopathic, called spontaneous pneumoperitoneum (SP), which may pose a diagnostic dilemma, especially when evaluating a patient who had no or minimal abdominal findings. Common cause of iatrogenic pneumoperitoneum is laparotomy or laparoscopic procedures. Subclinical small visceral perforation may occur, permitting only the leakage of air and not the bowel contents.

A 70-year-old male admitted with breathlessness since 4 days, abdominal pain, abdominal distension since 3 days and decreased urine output since 1 day, a known case of asthma [Figure 1] and [Figure 2]. On examination, tachycardia present. Examination of the abdomen revealed generalized tenderness, obliteration of liver dullness and absent bowel sounds. On auscultation Expiratory, wheeze heard all over the chest. Total count normal.
Figure 1: X-ray abdomen supine showing air outlining both sides of bowel wall: Rigler's sign (Double wall sign)

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Figure 2: Computed tomography axial sections using lung window settings showing free air outlining the falciform ligament suggestive of pneumoperitoneum

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In view of suspected tension pneumopritoneum, patient was subjected to laparotomy. On opening the peritoneum, a gush of air was detected. No perforation was detected in any segment of the bowel, and there was no intraperitoneal or retroperitoneal fluid collection. Abdominal drains were placed, and abdomen was closed. Postoperatively, patient developed respiratory acidosis from day 2 and platelet count started decreasing. On 6 th day, patient had burst abdomen for which tension suturing was done. On 11 th day, patient was put on a ventilator in view of falling saturation, respiratory distress and low Glasgow Coma Scale. Later on patient developed hypoxic encephalopathy and also went into sepsis and expired.

In 10% of cases of non-iatrogenic pneumoperitoneum, where the cause is not due to any perforated hollow viscous, the term SP is used. [1] SP is associated with intrathoracic, intraabdominal, gynecologic, iatrogenic. Abdominal causes are pneumatosis cystoids intestinalis, clostridium Infection, penetrating wound abdomen, gas-containing pyogenic liver abscess, jejunal, duodenal and sigmoid diverticulosis. [2] Thoracic causes are the most common etiology of SP due to alveolar rupture and subsequent movement of extra-alveolar air into the perivascular sheaths towards the mediastinum and retroperitoneal space, which may rupture intraperitoneally. Causes are asthma, chronic obstructive pulmonary disease, tuberculosis and cardiopulmonary resuscitation. SP is seen after pelvic examination, hysterosalpingography, tracheostomy, dental extraction, aerophagia. [3] The management of SP is a surgical dilemma [4] as a conservative approach is the rule in the management of this benign entity. A detailed history and physical examination can be helpful in distinguishing surgical from non-surgical pneumoperitoneum, thus avoiding unnecessary laparotomies. Moreover, radiographic imaging [5] before and after air insufflation into the gastric lumen via a nasogastric tube (pneumogastrogram) is an easy and safe method, which can enhance or confirm the diagnosis of a visceral perforation in the upper gastrointestinal (GI) tract Multidetector computed tomography is highly accurate for predicting the site of GI tract perforations.

Spontaneous pneumoperitoneum is a surgical dilemma, which requires proper assessment by thorough history and physical examination with no or minimal abdominal findings with history of respiratory diseases. After excluding GI tract perforation non-surgical management is best the option. All the surgeons should be aware of condition SP.

 
  References Top

1.
Madura MJ, Craig RM, Shields TW. Unusual causes of spontaneous pneumoperitoneum. Surg Gynecol Obstet 1982;154:417-20.  Back to cited text no. 1
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2.
Hirano Y, Hara T, Nozawa H, Nakada K, Oyama K, Hada M, et al. Asymptomatic spontaneous pneumoperitoneum complicating duodenal diverticulum. Indian J Surg 2006;68:99-101.  Back to cited text no. 2
    
3.
Tiwary SK, Agarwal A, Kumar S, Khanna R, Khanna AK. Idiopathic massive pneumoperitoneum. Internet J Surg 2006;8. Available from: https://ispub.com/IJS/8/2/5225 [Last accessed on 2015 Mar 4].  Back to cited text no. 3
    
4.
Derveaux K, Penninckx F. Recurrent "spontaneous" pneumoperitoneum: A diagnostic and therapeutic dilemma. Acta Chir Belg 2003;103:490-2.  Back to cited text no. 4
    
5.
Chiu YH, Chen JD, Tiu CM, Chou YH, Yen DH, Huang CI, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Am J Emerg Med 2009;27:320-7.  Back to cited text no. 5
    


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