Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma to the surgeons faced with this problem. Two such cases and their outcome are presented. The first case was caused by tracheal rupture during emergency intubation and was treated by observation until complete resolution. The second case was caused by barotrauma during positive pressure ventilation and was treated by laparotomy. Both patients died for reasons unrelated to the pneumoperitoneum. The passage of air from the chest cavity into the abdominal cavity was along the great vessels in the first case and through the diaphragm in the second. A compilation of other aetiologies of pneumoperitoneum without peritonitis as extracted from the literature is presented. In the presence of pneumoperitoneum without peritonitis and when the clinical history does not suggest visceral perforation, an abdominal tap or lavage should be attempted. If negative, continued observation is advised.
Pneumoperitoneum is almost always pathognomonic of a perforated abdominal viscus requiring urgent surgical intervention. Spontaneous or non-surgical pneumoperitoneum is a rare clinical condition arising secondary to abdominal, thoracic, gynaecologic or idiopathic causes. In addition to good clinical judgement, an important component in the management process is to rule out other causes of pneumoperitoneum by performing appropriate investigations. We describe a 60-year-old man who presented with clinical features of pseudo-obstruction, following an injury to his back which was compounded by hypokalaemia. Roentgenography revealed massive pneumoperitoneum and colonic distension. As there were no overt clinical features of peritonitis, the patient was managed conservatively with parenteral nutrition and close observation. A water-soluble contrast enema and computed tomography of the abdomen were of no help in identifying the cause of his pneumoperitoneum but were helpful in eliminating the presence of hollow viscus perforation or an obvious inflammatory focus. The aetiology of pneumoperitoneum in our patient was most likely due to dissection of air through the distended colonic wall, secondary to large bowel pseudo-obstruction. The diagnosis of spontaneous or non-surgical pneumoperitoneum is one of exclusion and we stress the importance of relying on clinical parameters when managing such patients conservatively.
The differentiation between a pseudo-pneumoperitoneum and true pneumoperitoneum on an initial chest radiograph is challenging but essential to clinical practice. The former is managed conservatively whereas the latter may require surgical intervention. Chilaiditi's sign describes a rare incidental radiological finding of gas filled bowel interpositioned between the right hemi-diaphragm and the liver, which is visible on a plain abdominal or chest radiograph. It is often misdiagnosed as a pneumoperitoneum. Correct diagnosis of Chilaiditi's sign in an asymptomatic patient can prevent unnecessary procedures. We have reported one incidental chest radiograph with Chilaiditi's sign in a patient presenting and treated for pneumonia. The report aims to illustrate the diagnostic dilemma experienced by clinicians in distinguishing a true versus pseudo-pneumoperitoneum on a chest radiograph.
Chilaiditi's sign describes the incidental radiographic finding of the bowel positioned between the right diaphragm and the liver. This is often misdiagnosed as pneumoperitoneum or free air under the diaphragm, which may lead to unnecessary investigations or surgical procedures. Here, we report two incidental chest radiograph findings of air under the diaphragm in patients who were being screened for pulmonary tuberculosis. This case series highlights the importance of awareness of the diagnosis of Chilaiditi's sign to avoid unnecessary hospital referrals.
A 4-month-old healthy male infant underwent left herniotomy under general anesthesia with caudal block. Carbon dioxide (CO2) pneumoperitoneum was created through the left hernial sac for inspection of the right processus vaginalis. Episodes of desaturation associated with significant reduction in chest compliance were noted intraoperatively. This was overcome by increasing the inspired oxygen concentration (FiO2). The infant failed to regain consciousness and spontaneous respiration at the end of surgery. The chest compliance deteriorated further and clinically a CO2 pneumothorax (capnothorax) was suspected. The endtidal carbon dioxide (P(E)CO2) was initially low in the immediate postoperative period. Subsequent to the readministration of sevoflurane and manual ventilation with a Jackson Rees circuit, a sudden surge in P(E)CO2 with improvement of chest compliance was observed. At that time arterial blood gas (ABG) analysis revealed a PCO2 of 17.5 kPa (134 mmHg) and pH of 6.9. The causes of severe hypercarbia and the physiological changes observed in this infant are discussed.
We describe a 50-year-old Chinese woman who had severe gastrointestinal manifestations from systemic sclerosis complicated by spontaneous pneumoperitoneum in the absence of either visceral perforation or pneumatosis cystoides intestinalis. This is a rare complication of systemic sclerosis; only four other cases have been reported. Recognition of this condition is important so as to avoid unnecessary surgery.