Urological pathology causing free air under the diaphragm?

Abstract

We report a case of long-standing, keratinising, squamous metaplasia of the bladder with undiagnosed malignant transformation to squamous cell carcinoma presenting as acute peritonitis secondary to spontaneous perforation of the bladder tumour. This presentation as an acute abdomen mimicking a perforated peptic or duodenal ulcer is the most unusual aspect of the case.

Urosepsis complicated by a spontaneous bladder perforation

“…Many of the documented cases involve diabetic patients 2 3 9. Alcoholism is also implicated in spontaneous bladder rupture due to altered sensitivity 2…”

“…Neoplasms, for example, transitional cell and squamous cell carcinomas may also lead to bladder rupture from tumour necrosis and ulceration 8–10 13. Intravesicular bladder neck obstruction from calculi or papillomas may cause increased pressure and spontaneous rupture 12…”

“…Patients presenting with abdominal pain and signs of peritonitis are commonly thought to have perforation of a peptic or duodenal ulcer 9. Spontaneous bladder rupture is relatively uncommon, but the diagnosis should be suspected in patients with previous history of pelvic irradiation, enterocystoplasty or bladder tumour 2 9. There is a published case of a diabetic patient with recurrent urinary tract infections and urinary incontinence presenting with abdominal pain and found to have rupture of the peritoneal bladder 2…”

“…Ultrasound may show fluid collections in the abdomen. Computed axial tomography (CAT) scan may be helpful in diagnosing spontaneous urinary bladder rupture 2 4 8 9 11. Findings have included free intraperitoneal fluid, free air under the diaphragm, thickened bladder wall, abscess, bowel obstruction and thick-walled bowel in the pelvis 2 8 9 11…”

“…CAT scan may be diagnostic or reveal significant clues to the cause of the abdominal pain, such as free fluid in the pelvis, thickened loops of bowel near the bladder, bladder wall thickening, abscess, or pneumoperitoneum 2 8 9 11. The patient should be urgently evaluated by urological and general surgeons and aggressively resuscitated.…”