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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.

Sore Throat
  • Adverse events associated with LMA such as blood staining on the mask and sore throat were also recorded. Within each group, the OLP was higher in the supine position than that in the lateral position with or without pneumoperitoneum (P 0.01).[ncbi.nlm.nih.gov]
  • The rate of postoperative sore throat was also significantly lower in the i-gel group than in the ETT group (3/17 vs 9/11).[ncbi.nlm.nih.gov]
Chest Wall Pain
  • To our knowledge, we present the first case of a non-iatrogenic and traumatic simultaneous pneumoperitoneum and pneumomediastinum in a previously independent 91-year-old man who presented to hospital with back and chest wall pain following mechanical[ncbi.nlm.nih.gov]
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]
  • 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]
  • 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]
  • (12%), tuberculosis (10%), and trauma (9%).[ 4 ] Similar results were seen by Jhobta et al. in their study of 504 consecutive cases.[ 5 ] Common signs and symptoms are abdominal pain, vomiting, abdominal distension, constipation, fever, diarrhea, tachycardia[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]
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]
Intestinal Perforation
  • 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]
  • Table 2 Management of patients diagnosed with intestinal perforation following endoscopy at our surgical department between October 2005 and October 2010.[bmcgastroenterol.biomedcentral.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]
Left Ventricular Dysfunction
  • Left ventricular dysfunction assessed in echocardiography as contractile abnormalities and decreased global longitudinal strain (GLS) represented an unusual type of TC - intermediate between mid-basal and focal one.[ncbi.nlm.nih.gov]
Otorrhagia
  • We present the first reported case of bilateral spontaneous otorrhagia associated with robotically assisted laparoscopic surgery involving a reduced Trendelenburg position and low-pressure pneumoperitoneum.[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]
Altered Mental Status
  • An 83-year-old man with indwelling Foley catheter presented to the ED for hematuria and altered mental status.[ncbi.nlm.nih.gov]
Lethargy
  • 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]

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
  • 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]
  • Immediately before pneumoperitoneum, variables were measured at baseline I and were then measured every min for 5 min after pneumoperitoneum start.[ncbi.nlm.nih.gov]
  • This study provides evidence of using low pressure pneumoperitoneum during LC as changes in FV hemodynamics and coagulation parameters were less pronounced at low pressure pneumoperitoneum.[ncbi.nlm.nih.gov]
  • Nonetheless, the cause of pneumoperitoneum remains unclear. We hypothesize that the right sized perforation (range: 2 mm to 4 mm in diameter) at the anterior wall of the stomach is needed for pneumoperitoneum to occur.[ncbi.nlm.nih.gov]

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]
  • Their course was favourable under conservative non-surgical approach associated with interruption of chemoterapy treatment.[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]
  • 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]
  • In this study, we investigate the diagnosis and treatment of BPPT in children.[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

  • The most well-accepted etiology is an increase in arterial and venous pressures causing the rupture of subcutaneous capillaries, although the exact etiology remains unclear.[ncbi.nlm.nih.gov]
  • 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]
  • Pneumoperitoneum and cystic intestinal pneumatosis associated to chemotherapy treatment are rare entities, with non-well stablished etiology and controversial management.[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]
  • 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]

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]
  • 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]

Prevention

  • Neonatal pneumoperitoneum is a surgical emergency indicative of gastrointestinal perforation that requires immediate treatment to prevent death.[ncbi.nlm.nih.gov]
  • Right stellate ganglion block can reduce blood catecholamines during CO2-pneumoperitoneum to maintain perioperative hemodynamic stability and prevent adverse cardiovascular events in elderly patients.[ncbi.nlm.nih.gov]
  • All patients except for one case of laparotomy were conservatively treated and cured with fasting, infection prevention, rehydration, abdominocentesis, and close observation. Nine cases of patients were all discharged with no death occurrence.[ncbi.nlm.nih.gov]
  • Team involvement and examination under anaesthesia could have prevented a laparatomy in this situation.[academic.oup.com]
  • 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.[symptoma.com]

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