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Pneumoperitoneum

The presence of free gas within the peritoneal cavity is referred to as pneumoperitoneum. This condition is most commonly encountered in patients who suffered a perforation of the gastrointestinal tract and thus indicates the necessity of urgent intervention to prevent peritonitis, septic shock, and death.


Presentation

PP patients may have a medical history of gastrointestinal disease or recent surgery, and corresponding anamnestic data should be considered when interpreting clinical signs, before deciding on a therapeutic approach. While the presence of free air in the peritoneal cavity cannot be diagnosed during a general examination, abdominal distension, intense pain, rigidity and rebound tenderness are indicative of peritonitis and possibly GIT perforation. In these cases, bowel sounds are usually absent and patients present constitutive symptoms like fever, volume depletion, hypotension and tachycardia; they may suffer from nausea and vomiting. Furthermore, patients may report not to have passed stools or gasses since symptom onset [1].

In contrast, postoperative PP doesn't generally cause major complaints, and mild to moderate abdominal distension and pain may merely result from the underlying disease or surgery. This condition should normalize within a week.

Fever
  • The patient presented with chronic pain abdomen and fever which later evolved to acute abdomen during the course of hospital stay.[ncbi.nlm.nih.gov]
  • Pneumoperitoneum observed up to 48 d status post laparoscopic hysterectomy, in the absence of peritoneal signs, fever, leukocytosis, or hemodynamic instability, may be considered for expectant management and serial inspection for clinical change.[ncbi.nlm.nih.gov]
  • Close clinical observation and symptomatic treatment are usually all that is required but operative interventions should be considered if the patient develops abdominal pain, peritoneal signs, fever or leukocytosis during observation.[ncbi.nlm.nih.gov]
  • Patients were all admitted to hospital with the major clinical symptom of abdominal distension, including 2 cases accompanied by tachypnea, 2 cases with vomiting, 1 case with diarrhea, and 2 cases with fever.[ncbi.nlm.nih.gov]
  • Research , Park et al. retrospectively reviewed 193 patients who underwent PEG placement and reported that 9 (4.6%) patients had a pneumoperitoneum on post-PEG radiographic imaging. 6 Clinically significant signs were observed in 5 (55.5%) patients, with fever[ncbi.nlm.nih.gov]
Developmental Delay
  • Four children had global developmental delay and were percutaneous endoscopic gastrostomy or jejunostomy fed, one was immunocompromised (acute lymphoblastic leukemia). The others had encephalitis and eosinophilic gastroenteritis.[ncbi.nlm.nih.gov]
Constitutional Symptom
  • In these cases, bowel sounds are usually absent and patients present constitutive symptoms like fever, volume depletion, hypotension and tachycardia; they may suffer from nausea and vomiting.[symptoma.com]
Recurrent Chest Pain
  • CASE EXAMPLE: A typically young, otherwise healthy woman comes into the emergency department of Stanford University, California, complaining of recurrent chest pain.[ncbi.nlm.nih.gov]
Intestinal Perforation
  • Abstract Pneumoperitoneum in preterm infants is a surgical emergency as it is usually indicative of intestinal perforation.[ncbi.nlm.nih.gov]
  • In neonate with intestinal perforation one should consider Hirschsprung's disease.[ncbi.nlm.nih.gov]
  • Non-NEC causes were spontaneous intestinal perforation (8.9%), ano-rectal malformations (7.1%), Hirschsprung's disease (14.2%), ileal atresia (3.5%), incarcerated inguinal hernia (1.7%), gastric perforation (1.7%) and meconium ileus (1.7%).[ncbi.nlm.nih.gov]
  • As for the five neonates (8.9%) having intestinal perforations without features suggestive of NEC or other intestinal anomalies, spontaneous intestinal perforation (SIP) was the appropriate diagnosis. One out of five had an ileal perforation.[afrjpaedsurg.org]
  • Peritoneal drainage versus laparotomy as initial surgical treatment for perforated necrotizing enterocolitis or spontaneous intestinal perforation in preterm low birth weight infants.[ncbi.nlm.nih.gov]
Increased Abdominal Girth
  • Report of a Case A 63-year-old man with a long-standing history of alcohol abuse was admitted to the hospital in September 1980 with increasing abdominal girth, increasing[jamanetwork.com]
Hyperactive Bowel Sounds
  • Physical examination revealed all patients with relaxed abdominal wall except 1 patient with abdominal distension had slight muscle stiffness and hyperactive bowel sounds. Abdominal X-ray suggested free air under the diaphragm in all cases.[ncbi.nlm.nih.gov]
Thrombosis
  • Lower limb venous stasis is one of the major pathophysiological elements involved in the development of peri-operative deep vein thrombosis.[ncbi.nlm.nih.gov]
Petechiae
  • An emergency laparotomy showed petechia along the anterior gastric wall, haematoma of lesser omentum but showed no evidence of gastrointestinal perforation or organ injury.[ncbi.nlm.nih.gov]
Lethargy
  • INTRODUCTION: Hirschsprung's disease is a congenital colonic aganglionosis, usually presented as inability or difficulty in passing of meconium, chronic and persistent obstipation, maleficent feeding, vomiting, distension and lethargy.[ncbi.nlm.nih.gov]
Hyperactivity
  • Physical examination revealed all patients with relaxed abdominal wall except 1 patient with abdominal distension had slight muscle stiffness and hyperactive bowel sounds. Abdominal X-ray suggested free air under the diaphragm in all cases.[ncbi.nlm.nih.gov]
Hematuria
  • CASE REPORT: An 83-year-old man with indwelling Foley catheter presented to the ED for hematuria and altered mental status.[ncbi.nlm.nih.gov]

Workup

Abdominal imaging is the mainstay of PP diagnosis. To this effect, plain radiography has long since been the technique of first choice. Very small volumes of free gas - as little as 1 ml - can be observed in images obtained by means of this technique. Upright, anterior-posterior chest radiographs are most suited and typically depict a translucent, crescent area below the diaphragm [7]. The Rigler's sign may be observed; it corresponds to the display of both sides of the intestinal wall [8]. Similarly, the telltale triangle sign implies PP: A triangle of gas may be visualized between three adjoining bowel loops, or two loops and the peritoneal wall [9]. In emergency settings, radiographs may be obtained from a patient in the supine decubitus position.

Computed tomography scans may be reserved for doubtful cases. Its superior spatial resolution is helpful to localize minimum quantities of free gas and to distinguish PP from pseudo- pneumoperitoneum. The latter term refers to any condition that mimics PP, such as pneumatosis cystoides intestinalis and interposition of viscera [10].

Pneumoperitoneum
  • […] detection of pneumoperitoneum.[ncbi.nlm.nih.gov]
  • INTERVENTIONS: Patients were allocated into 3 groups: Group 1: low-pressure pneumoperitoneum with moderate-NMB (1-3 TOF), Group 2: low-pressure pneumoperitoneum with deep-NMB (1-5 PTC) and Group 3: standard pneumoperitoneum (12mmHg).[ncbi.nlm.nih.gov]
  • The effects of nitrous oxide and helium pneumoperitoneum compared with carbon dioxide pneumoperitoneum are uncertain.[ncbi.nlm.nih.gov]
  • Mularski RA, Ciccolo ML, Rappaport WD : Nonsurgical causes of pneumoperitoneum. West J Med 1999; 170: 41-46. 2. Van Gelder HM, Allen KB, Renz B et al.: Spontaneous pneumoperitoneum. A surgical dilemma. Am Surg 1991; 57: 151-56. 3.[doi.org]
  • […] selected to be involved in the study, and labeled as surgical pneumoperitoneum or pneumoperitoneum-induced peritonitis.[dx.doi.org]
Clostridium Perfringens
  • Ascitic fluid culture yielded Clostridium perfringens , suggesting a diagnosis of SBP.[jamanetwork.com]

Treatment

  • Once the fistula is diagnosed, treatment options are several. Conservative versus operative treatment is currently a matter of debate generally regarding timing, patient's condition and fistula's size.[ncbi.nlm.nih.gov]
  • The aim was to determine if peritoneal drainage (PD) is a suitable treatment for pneumoperitoneum in extremely low birth weight (ELBW) infants.[ncbi.nlm.nih.gov]
  • In this study, we investigate the diagnosis and treatment of BPPT in children.[ncbi.nlm.nih.gov]
  • BACKGROUND: The surgical treatment of giant incisional hernias with loss of domain is challenging due to the possibility of intra-abdominal hypertension after the herniated content is returned to the peritoneal cavity.[ncbi.nlm.nih.gov]
  • We herein report the case of a 73-year old man who received treatment with an alpha glucosidase inhibitor (acarbose) and presented with acute abdomen.[ncbi.nlm.nih.gov]

Prognosis

  • Delay in recognizing and treatment can significantly worsen prognosis. In neonate with intestinal perforation one should consider Hirschsprung's disease.[ncbi.nlm.nih.gov]
  • In 1957 Wolcott and Murphy 1 stated that the prognosis and management of lung abscess has changed dramatically in the past 15 years. They reported on 70 patients treated since 1941.[jamanetwork.com]
  • Asymptomatic pneumomediastinum has good prognosis and it resolves spontaneously. Pneumopericardium and pneumoperitoneum are rare event. But when pneumomediastinum is accompanied with pneumopericardium and symptomatic, the prognosis gets worse.[omicsonline.org]
  • Treatment The treatment and prognosis of pneumoperitoneum depend on its cause. The initial step of treatment is identifying the underlying condition that causes the air retention within the peritoneal cavity.[hubpages.com]

Etiology

  • It can be due to either of surgical or non-surgical etiology. Here we present a case of gas under right dome of diaphragm caused by a non-surgical cause i.e. secondary to aspiration of liver abscess.[ncbi.nlm.nih.gov]
  • […] pneumothorax (CP) is considered to be an extremely rare entity, characterized by recurrent pneumothorax occurring between the day before and within 72 hours after the onset of menses, usually in the right-side thorax cavity in women of reproductive age.The etiology[ncbi.nlm.nih.gov]
  • Abstract Pneumatosis cystoides intestinalis (PCI), with an unknown etiology, is an uncommon disease characterized by the presence of multiple gas-filled cysts within the submucosa or subserosa of the intestinal wall.[ncbi.nlm.nih.gov]
  • Pneumoperitoneum has a wide differential diagnosis and presents with varying degrees of severity; however, not all etiologies require operative intervention. It is imperative that all patients with this diagnosis are evaluated by a surgeon.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Our case provides evidence supporting the theory that anaerobic infection may underlie the etiology of tension pneumoperitoneum.[ncbi.nlm.nih.gov]

Epidemiology

  • Stroup DF, Berlin JA, Morton SC, et al; Meta-analysis of Observational Studies in Epidemiology (MOOSE) Group. Meta-analysis of observational studies in epidemiology: a proposal for reporting. JAMA . 2000;283(15):2008-2012.[dx.doi.org]
  • Pathogenesis and epidemiology Perforation complicates duodenal ulcer about half as often as bleeding and most perforated ulcers are on the anterior surface of the duodenum.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • Rare cases of idiopathic pneumoperitoneum have been described in the literature, the underlying causes and pathophysiology of which remain uncertain.[ncbi.nlm.nih.gov]
  • In cases of atypical non-surgical pneumoperitoneum in sexually active women, a careful inquiry into the medical-sexual history can reveal the cause of pathophysiology without comprehensive, painful and unnecessary diagnostics.[ncbi.nlm.nih.gov]
  • Lower limb venous stasis is one of the major pathophysiological elements involved in the development of peri-operative deep vein thrombosis.[ncbi.nlm.nih.gov]
  • In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas.[ncbi.nlm.nih.gov]

Prevention

  • The gastric leak self-seals, preventing further passage of the air, allowing the intraperitoneal free gas to dissipate gradually.[ncbi.nlm.nih.gov]
  • Clinicians should be aware of this condition and focus on medical-sexual history as this information could prevent a patient from being exposed to expensive diagnostics and invasive operative treatments.[ncbi.nlm.nih.gov]
  • To prevent pneumatic perforation during upper GI endoscopy, patients should be well prepared and fasted prior to the examination.[ncbi.nlm.nih.gov]
  • Embarrassment and modesty often prevent the patient from talking about sexual activity. Sexual pneumoperitoneum is not a bizarre sex accident but a rare and serious patho-mechanism.[ncbi.nlm.nih.gov]
  • INTERVENTIONS/OUTCOMES: All patients except for one case of laparotomy were conservatively treated and cured with fasting, infection prevention, rehydration, abdominocentesis, and close observation.[ncbi.nlm.nih.gov]

Summary

The term pneumoperitoneum (PP) refers to the presence of gas within the peritoneal cavity. Most commonly, this gas originates from the gastrointestinal tract (GIT) and thus indicates a disruption of its physical integrity. Any part of the GIT may be affected and PP may complicate diseases like gastric ulcer, mesenteric infarction, toxic megacolon, and abdominal cancer. Interestingly, perforated appendicitis seldom entails PP [1]. Rarely, emphysematous inflammation of abdominal organs may give rise to PP [2]. PP may also occur after penetrating abdominal trauma or abdominal surgery. Postoperative PP may or may not indicate leaking anastomoses, since air may be introduced into the peritoneal cavity during surgery [3]. Indeed, PP may be induced intentionally by insufflation of carbon dioxide or helium to facilitate laparoscopic procedures and intraperitoneal chemotherapy [4]. Although such a measure may be contraindicated in patients suffering from cardiorespiratory disorders and increased intracranial pressure [5] [6], the presence of gas within the abdominal cavity per se is not detrimental. However, pathological PP as described above is virtually always associated with the presence of pathogens and toxins in the peritoneal cavity. Therefore, it is an indicator of a life-threatening situation that requires emergency surgery.

References

Article

  1. Campos Canelas AL, Fernandez HM, Crociati Meguins L, et al. Pneumoperitoneum in association with perforated appendicitis in a Brazilian Amazon woman. Case report. G Chir. 2010;31(3):80-82.
  2. Hateley C, Alcada J, Park M, Vaid N, Buckley J. Pneumoperitoneum, a urological source. Lancet. 2016;387(10015):284.
  3. Lee CH, Kim JH, Lee MR. Postoperative pneumoperitoneum: guilty or not guilty? J Korean Surg Soc. 2012;82(4):227-231.
  4. Henretta MS, Anderson CL, Angle JF, Duska LR. It's not just for laparoscopy anymore: use of insufflation under ultrasound and fluoroscopic guidance by Interventional Radiologists for percutaneous placement of intraperitoneal chemotherapy catheters. Gynecol Oncol. 2011;123(2):342-345.
  5. Neuhaus SJ, Gupta A, Watson DI. Helium and other alternative insufflation gases for laparoscopy. Surg Endosc. 2001;15(6):553-560.
  6. Kamine TH, Elmadhun NY, Kasper EM, Papavassiliou E, Schneider BE. Abdominal insufflation for laparoscopy increases intracranial and intrathoracic pressure in human subjects. Surg Endosc. 2016;30(9):4029-4032.
  7. Pinto A, Miele V, Schilliro ML, et al. Spectrum of Signs of Pneumoperitoneum. Semin Ultrasound CT MR. 2016;37(1):3-9.
  8. Rigler LG. Spontaneous pneumoperitoneum: A roentgenologic sign found in the supine position. Radiology. 1941;37:604–607.
  9. Huang MY, Chang WH. Images in clinical medicine. Telltale triangle of pneumoperitoneum. N Engl J Med. 2009;361(1):73.
  10. Lo BM. Radiographic look-alikes: distinguishing between pneumoperitoneum and pseudopneumoperitoneum. J Emerg Med. 2010;38(1):36-39.

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Last updated: 2018-06-22 07:35