IDIOPATHIC SPONTANEOUS PNEUMOPERITONEUM IN A

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A
SY Chee, R Milling, M Khanzada, A Harmour, M Megally, M Aremu
Department of General Surgery, Connolly Hospital Blanchardstown, Dublin, Ireland.

INTRODUCTION DISCUSSION

Pneumoperitoneum is most often caused by a perforation of a hollow viscus Causes of Pneumoperitoneum

and is often considered a surgical emergency. However, idiopathic
spontaneous pneumoperitoneum is a rare condition that is characterized by
intraperitoneal gas without gastrointestinal tract perforation, for which there • Viscus Perforation (surgical) - 90%
is no clear identification of any etiology.caused by a perforation of a hollow viscus Perforated duodenal/gastric ulcer;
and is often considered a surgical emergency. However, idiopathPneumoperitoneum is most often Ruptured diverticulum; Bowel obstruction; Penetrating trauma;
caused by a perforation of a hollow viscus and is often considered a surgical emergency. Howev er, idiopathic Ruptured inflammatory bowel disease (e.g., megacolon);
Necrotising enterocolitis/pneumatosis coli; Bowel cancer,
spontaneous pneumoperitoneum is a rare condition that is characterized by intraperitoneal gas without gastrointestinal tract perforation, for which there is no clear identification of any etiology.ic spontaneous pneumoperitoneum is a rare condition that is characterized by intraperitoneal gas without gastrointestinal tract perforation, for which there is no clear identification of any etiology.en caused by a perforation of a hollow viscus and is often considered a
surgical emergency. The most recognized cause of spontaneous pneumoperitoneum is due to a perforated peptic ulcer. In a small proportion of pneumoperitoneum, it can occur without any evidence of intraperitoneal perforation and are grouped as spontaneous or idiopathic  pneumoperitoneum. urgical emergency. The most recognized cause of spontaneous pneumoperitoneum is due to a perforated peptic ulcer. In a small proportion of pneumoperitoneum, it
can occur without any evidence of intraperitoneal perforation and are grouped as spontaneous or idiopathic  pneumoperitoneum. 
umoperitoneum is most often caused by a perforation of a hollow viscus and is often considered a surgical emergency. The most recognized cause of spontaneous pneumoperitoneum is due to a perforated peptic ulcer. In a small proportion of pneumoperitoneum, it can occur without any evidence of intraperitoneal perforation and are grouped as spontaneous or idiopathic  pneumoperitoneum. 

Ischemic bowel; Steroids; Bowel injury after endoscopy; Breakdown

of a surgical anastomosis; Uterine rupture; Iatrogenic - after
CASE REPORT laparotomy, laparoscopy and colonoscopy.
Fig.1. Erect Chest X-ray showing Pneumoperitoneum. Fig.2 Axial CT showing Pneumoperitoneum
We describe a case of an 18-year-old female who presented to
the emergency department with left shoulder tip pain and upper • Spontaneous (non-surgical) - 10%
abdominal discomfort. On examination, she had a normal vital Presence of free air in the peritoneum without evidence of any
signs and her abdomen was soft and non-tender. Blood perforation of hollow viscera.
investigations showed: WCC - 19x109/L, CRP - 2.11 mg/L, Pneumothorax(e.g., bronchopleural fistula); Mechanical
Hb - 13 xmmol/L, Lactate - 1.43 mmol/L, Urea and Electrolytes ventilation can force air down trachea; Vaginal insufflation (air
– normal, and LFT - normal. Urinalysis was normal and the enters via the fallopian tubes); Pneumatosis cystoides
intestinalis/coli; Spontaneous bacterial peritonitis;
pregnancy test was negative.
Emphysematous cholecystitis
She had an erect chest X-ray which showed air under the
diaphragm indicative of a pneumoperitoneum (Fig.1).
Subsequently, she had a CT abdomen pelvis which
Idiopathic Spontaneous Pneumoperitoneum
Fig. 3. OGD - Normal Fig. 4. Chest X-ray 2 weeks post discharge - Normal
demonstrated pneumoperitoneum but the source could not be •Definition: Presence of free air in the peritoneal cavity with no
identified on imaging (Fig, 2). She also had an OGD which was cause found. Very rare.
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normal (Fig.3)..She was well and vitally stable throughout her CONCLUSION
admission. She was monitored for 48 hours in hospital and was •Symptoms: Abdominal pain, Distention.
A detailed medical history, physical examination, appropriate
subsequently discharged home. She was followed up in our laboratory tests and radiological investigations are valuable tools •Signs: Kerr’s sign
outpatient clinic two weeks after discharge and remained to identify patients with non-surgical pneumoperitoneum.
clinically well. Her repeat erect chest X-ray at the 2 weeks •Imaging: Free air under diaphragm, Intraperitoneal free air
Knowledge of this rare disease will help in avoiding unnecessary
outpatient clinic visit showed complete resolution of her laparotomy. •Treatment: Conservative
pneumoperitoneum (Fig.4).