Massive Pneumoperitoneum Presenting as an Incidental Finding

Abstract

Pneumoperitoneum is often associated with surgical complications or intra-abdominal sepsis. While commonly deemed a surgical emergency, pneumoperitoneum in a minority of cases does not involve a viscus perforation or require urgent surgical management; these cases of “spontaneous pneumoperitoneum” can stem from a variety of etiologies. We report a case of a 72-year-old African American male with a history of metastatic pancreatic adenocarcinoma who presented with new-onset abdominal distention and an incidentally discovered massive pneumoperitoneum with no clear source of perforation on surveillance imaging. His exam was non-peritonitic, so no surgical intervention was recommended. He was treated with bowel rest, intravenous antibiotics, and hydration. He had a relatively benign clinical course with preserved gastrointestinal function and had complete resolution of his pneumoperitoneum on imaging two months after discharge. This case highlights the importance of considering non-surgical causes of pneumoperitoneum, as well as conservative management, when approaching patients with otherwise benign abdominal exams.

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

“…Non-surgical pneumoperitoneum (NSP) is found less frequently [[6], [7], [8]]. Intra-thoracic causes include thoracic trauma (such as barotrauma), post-cardio-pulmonary resuscitation and excessive mechanical ventilation with high peak inspiratory pressures [7,8].…”

“…Intra-thoracic causes include thoracic trauma (such as barotrauma), post-cardio-pulmonary resuscitation and excessive mechanical ventilation with high peak inspiratory pressures [7,8]. In these cases, pneumoperitoneum is usually a result of raised intra-thoracic pressure, which leads to the leakage of intrathoracic air through microscopic pleural and diaphragmatic defects, and pneumomediastinum often co-exists [2].…”

“…In these cases, pneumoperitoneum is usually a result of raised intra-thoracic pressure, which leads to the leakage of intrathoracic air through microscopic pleural and diaphragmatic defects, and pneumomediastinum often co-exists [2]. In such cases, management of pneumoperitoneum is typically conservative [7,8]. 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].…”

“…Such a finding certainly poses a significant challenge to the clinician with regards to investigation and management, particularly as the initial concern upon finding a pneumoperitoneum is of an acute gastrointestinal condition requiring urgent surgical intervention [1,8,9]. The patient with the incidentally found pneumoperitoneum frequently undergoes surgical exploration, putting them at risk of various surgical and anaesthetic complications associated with such an approach [3,9].…”

“…The pathophysiology of IP is poorly understood and is largely regarded a diagnosis of exclusion [2]. This group of patients require close attention to recognise those who can be safely managed conservatively, thereby avoiding unnecessary surgical intervention [1,8,9]. …”