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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]
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]
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]
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]
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[dx.doi.org]
Peritoneal Disease
  • Medium hochladen Wikipedia Ist ein(e) Krankheit Unterklasse von peritoneal disease, Emphysem Normdatei Q163469 Reasonator Scholia Statistik Unterkategorien Es werden 2 von insgesamt 2 Unterkategorien in dieser Kategorie angezeigt: In Klammern die Anzahl[commons.wikimedia.org]
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]
Weak Pulse
  • The patient's condition deteriorated, as he became confused and pale with rapid weak pulse and hypotension. His abdomen became barrel-shaped, tender, and tympanic to percussion.[dx.doi.org]
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]
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]
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]
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]
Renal Impairment
  • Anaesthesia for patients with renal impairment. Br J Hosp Med 1996; 55 : 171–5 [ PubMed ] [ Google Scholar ] 9. Wakeen MJ, Zimmerman SW, Bidwell D. Viscus perforation in peritoneal dialysis patients. Diagnosis and outcome.[ncbi.nlm.nih.gov]
Hematuria
  • 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
  • […] selected to be involved in the study, and labeled as surgical pneumoperitoneum or pneumoperitoneum-induced peritonitis.[oadoi.org]
  • […] detection of pneumoperitoneum.[ncbi.nlm.nih.gov]
Gastric Lesion
  • lesion 7, 8 or to the pneumatic perforation of a gastric or duodenal ulcer.[dx.doi.org]
Ischemic Changes
  • Therefore neoplastic cells were found in 8/131 cases, on the other hand 13/131 cases (9.9%) had evident ischemic changes and vasculopathy. [Table 3] 4.[oadoi.org]

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]

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]

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.[jamanetwork.com]
  • 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]

Prevention

  • Neonatal pneumoperitoneum is a surgical emergency indicative of gastrointestinal perforation that requires immediate treatment to prevent death.[ncbi.nlm.nih.gov]
  • To prevent pneumatic perforation during upper GI endoscopy, patients should be well prepared and fasted prior to the examination.[dx.doi.org]

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: 2019-06-28 11:55