Does pneumoperitoneum always require laparotomy? Report of six cases and review of the literature

Abstract

The presence of intraperitoneal free air signals perforation of a hollow viscus in over 90% of the patients. Rarely, however, the presence of pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. This condition, which poses a dilemma to the surgeon faced with this problem, is termed "nonsurgical", "spontaneous" or "idiopathic" pneumoperitoneum. Six cases of nonsurgical pneumoperitoneum admitted over a 2-year period to our institution are reported, and the etiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas are reviewed. Two of the six children with nonsurgical pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in one of these patients. In the other children, malrotation was found. Four patients, on ventilatory support, were managed conservatively after performing a diagnostic peritoneal lavage and/or contrast studies those were negative. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

Idiopathic Pneumoperitoneum in A Pediatric Patient: A Case Report

“…But in cases of non-surgical pneumoperitoneum with mild symptoms and without sings of peritoneal irritation we can try conservative treatment. [9] In our case, the patient presented pneumoperitoneum with fever and leukocytosis that is why surgical exploration was indicated.…”

“…[7]. Spontaneous pneumoperitoneum is characterized by a benign course and it can be managed conservatively [8,9].…”

Spontaneous idiopathic pneumoperitoneum with acute abdomen

“…Spontaneous peritoneum is associated with intrathoracic, intra-abdominal, gynecologic, iatrogenic, and other reasons (1,2). Trauma (including barotrauma), pneumothorax, and severe thoracic diseases such as broncho-peritoneal fistula can be complicated with SP (1).…”

“…While surgery is inevitable in the presence of signs and symptoms of acute abdomen, conservative treatment is indicated for mild symptoms without peritonitis (2). A detailed history and physical examination may be helpful in the differentiation of surgical and non-surgical pneumoperitoneum, (2).…”

“…SP is associated with intrathoracic, intra-abdominal, gynecologic, iatrogenic or various other reasons (1). Generally, SP is not complicated by peritonitis, is benign and can be treated conservatively (1)(2)(3)(4). Idiopathic SP is a very rare condition of unknown etiology, which can only be identified by exclusion of visceral perforation and other causes leading to presence of intra-abdominal free air (1,(5)(6)(7).…”