Uncommon cause of pneumoperitoneum

Abstract

Free intraperitoneal air is thought to be pathognomonic for perforation of a hollow viscus. Here, we present a patient with pain in the upper left quadrant, a mild fever and leukocytosis. Free air was suggested under the left diaphragm but during the explorative laparotomy no signs of gastric or diverticular perforation were seen. Further exploration and revision of the computed tomography revealed a perforated splenic abscess. Splenic abscesses are a rare clinical entity. Presenting symptoms are often non-specific and include upper abdominal pain, recurrent or persistent fever, nausea and vomiting, splenomegaly, leukocytosis and left lower chest abnormalities. Predisposing conditions can be very divergent and include depressed immunosuppressed state, metastatic or contiguous infection, splenic infarction and trauma. Splenic abscess should therefore be considered in a patient with fever, left upper abdominal pain and leukocytosis. Moreover, our case shows that splenic abscess can present in an exceptional way without clear underlying aetiology and should even be considered in the presence of free abdominal air.© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Spleen; Abscess; Pneumoperitoneum Core tip: Free intraperitoneal air is thought to be pathognomonic for perforation of a hollow viscus. Here, we present a patient with pain in the upper left quadrant, a mild fever and leukocytosis. Free air was suggested under the left diaphragm but during the explorative laparotomy no signs of gastric or diverticular perforation were seen. Further exploration and revision of the computed tomography revealed a perforated splenic abscess. Splenic abscesses are a rare clinical entity. Our case shows that splenic abscess can present in an exceptional way without clear underlying aetiology and should even be considered in the presence of free abdominal air.van Nunspeet L, Eddes EH, de Noo ME. Uncommon cause of pneumoperitoneum. World J Gastrointest Surg 2013; 5(12): 329-331 Available from:

Ruptured splenic abscess causing pneumoperitoneum: a rare cause revisited

“…Three aetiological causes of splenic abscesses have been proposed:5 trauma with secondary infection; per continuitatem; and haematogenous spread. Development by continuitatem has been described in perforated gastric ulcer, perinephric abscess, septic abortion, appendicitis with perforation and in the case of concomitant colon carcinoma.…”

Ruptured splenic abscess as an extremely rare cause of pneumoperitoneum: A comprehensive review with a case report

“…Therefore, similar pathogens must be causative agents in our patient, however, unfortunately, the blood and abscess culture had negative results which may be ascribed to early high-dose antibiotic therapy administration or a technical error. The results of either blood or splenic abscess culture were as follows in reported cases: Positive for Klebsiella pneumoniae and anaerobe Prevotella intermedia in pus culture from the splenic abscess [3] , positive pus culture for Enterobacter cloacae [6] , positive pus culture for b-hemolytic Streptococcus, Escherichia coli ( E coli ), Morganella morganii , and Proteus mirabilis from the perisplenic fluid and positive blood culture for b-hemolytic Streptococcus [7] , positive abscess culture for Prevotella intermedia [8] , negative blood cultures for any growth of bacteria [9] , positive pus culture from abscess for E coli and negative blood culture [4] , positive abscess aspirate culture for peptostreptococcus species [10] , positive pus culture for E coli [11] . In addition, the spleen histopathology revealed infiltration of a moderate quantity of Gram-positive bacteria in 1 patient [12] and in 1 case, there was not any data regarding microbial culture [5] .…”

“…We presented a case that was afflicted by a splenic abscess whose rupture led to pneumoperitoneum. Based on a comprehensive review of the literature, we found only 10 case reports illustrating pneumoperitoneum following the rupture of a splenic abscess [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] . The search strategy used for the purpose of discovering these articles was the utilization of the keywords "Splenic Abscess" AND "Pneumoperitoneum" in the databases of PubMed, Scopus, and Google Scholar Advanced Search.…”

“…Diabetes mellitus in 4 [ [4] , [5] , [6] , 8 ] and human immunodeficiency virus (HIV) infection [7] , ulcerative colitis under treatment with immunosuppressive drugs and splenic hypoperfusion [10] , and malignancy (colon cancer and melanosarcoma) [12] in 1 patient were reported. In the 3 other cases, immunocompromised status was not cited in the patient's past medical histories [ 3 , 9 , 11 ]. Our case was in line with most reported cases as she had a history of type I diabetes mellitus.…”

“…The diagnostic approach was quite diverse among case reports. Chest X-rays for pneumoperitoneum and exploratory laparotomy to investigate the cause which showed splenic abscess rupture were utilized in 4 patients [ 3 , 5 , 10 , 11 ], abdominal CT scans for both pneumoperitoneum and ruptured splenic abscess in 2 patients [ 6 , 7 ], chest X-ray for pneumoperitoneum and abdominal CT for splenic abscess rupture in 2 patients [ 4 , 8 ], chest X-ray for pneumoperitoneum, abdominal CT firstly did not diagnose splenic abscess but exploratory laparotomy for splenic abscess rupture in 1 patient [9] , and abdominal X-ray for pneumoperitoneum and abdominal CT for ruptured splenic abscess in 1 patient [12] were employed. This diversity mainly owes to the clinical condition of the patient as when the patient was clinically stable, a more advanced imaging modality was used.…”