Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver

Abstract

Abdominal compartment syndrome is a surgical emergency caused by a raised intra-abdominal pressure, which may lead to respiratory, cardiovascular and renal compromise. It is most commonly seen in post-operative and trauma patients and it has a variety of causes. Tension pneumoperitoneum (TP) is a rare cause of abdominal compartment syndrome most often seen after gastrointestinal endoscopy with perforation.We present the case of a fit 52-year-old experienced female diver who developed TP and shock following a routine training dive to 27m. Following accidental inhalation of water, she had an unstaged ascent and, on reaching the surface, developed severe acute abdominal pain and distension. She was brought to our emergency department by air ambulance for assessment. Clinical and radiological examination revealed a shocked patient with dramatic free intra-abdominal gas and signs of abdominal compartment syndrome, which was treated with needle decompression. Symptoms and signs resolved quickly with no need for further surgical intervention. TP is a surgical emergency where surgery can be avoided with prompt diagnosis and treatment.

The clinical dilemma of the persistent idiopathic pneumoperitoneum: A case report

“…In the female population, gynaecological causes such as sexual intercourse, vaginal douching, vaginal insufflation, and pelvic inflammatory disease, should be considered and are usually a result of anatomical communication between the peritoneal cavity and the fallopian tubes and endometrium [7]. In extremely rare cases, pneumoperitoneum may occur as a result of jacuzzi usage or scuba diving [11,12]. …”

“…The presence or absence of peritonitis on clinical examination and the underlying cause of pneumoperitoneum should determine whether treatment is surgical or not, as opposed to the mere presence of pneumoperitoneum alone. In cases of NSP without signs of peritonitis, conservative treatment with close observation is indicated [3,4,9,12,14]. With regards to identifying an underlying cause, the first step should be exclusion of gastrointestinal perforation, and this is best achieved by contrast-enhanced CT, which can predict the location of gastrointestinal perforation with 86% accuracy [15].…”

Massive Pneumoperitoneum Presenting as an Incidental Finding

“…Vaginal douching, insufflation, and even pelvic inflammatory disease have been associated with non-surgical pneumoperitoneum [3]. Several bizarre incidences of SP have been documented after jacuzzi usage [12], scuba diving [13], and even knee-chest exercises [14]. Finally, there are cases of SP that demonstrate no clear risk factors or cause for the presence of intraperitoneal free air with subsequent negative laparotomies; these are labeled idiopathic pneumoperitoneum [15].…”

A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients

“…Percutaneous catheter drainage can be used as a definitive treatment in some cases (e.g., ascites in liver cirrhosis [36], burn patients with ACS [37]), but can also be used as a temporary measure in cases where investigation of the underlying disease is ongoing but organ dysfunction requires urgent decompression (e.g., decompression of pneumoperitoneum before evaluation for gastrointestinal tract perforation [38]) or after definitive treatment of the underlying condition to treat any residual IAH/ACS (e.g., evacuation of free abdominal blood after endovascular aortic reconstruction for ruptured aortic aneurysm). This is a direct challenge to the classical adage that a diagnosis of overt ACS equals the need for decompressive laparotomy while, even in extreme circumstances, the etiology of ACS should be considered.…”