Non-Surgical Pneumoperitoneum: Exceptional Situation of Multiple Etiologies ()
1. Introduction
Pneumoperitoneum is a surgical emergency usually related to the perforation of an abdominal viscus [1]. Sometimes, a pneumoperitoneum may occur without perforation. Then it is described as spontaneous, iatrogenic, or linked to thoracic, abdominal, or gynecological causes. In these cases, it’s generally managed conservatively [2]. It is a diagnostic and therapeutic dilemma for the surgeon [3]. We report the case of a patient who presented with non-surgical pneumoperitoneum. Then, we discuss the different etiologies of this pathological entity.
2. Observation
A 39-year-old patient, tobacco sniffer, and never operated, was admitted to the emergency room for intermittent epigastric pain evolving in a feverish context for three days. Clinical examination found a conscious patient, hemodynamically and respiratory stable. The temperature was 38.1˚C, pulse 98/min, and blood pressure 130/80mmHg. The abdomen was slightly distended with epigastric tenderness. Laboratory investigations showed that the white blood cell count was 12,000/mm3, and the CRP level was 40 mg/dl. The plain abdominal X-ray demonstrated neither pneumoperitoneum nor gas-fluid levels. Thoracoabdominal CT scan showed a pneumomediastinum with pneumoperitoneum and subcutaneous cervical emphysema, without intraperitoneal effusion (Figure 1, Figure 2). There
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Figure 1. CT scan showing the pneumoperitoneum.
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Figure 2. CT scan showing pneumomediastinum and subcutaneous emphysema.
was no intestinal perforation. A thoracic origin was evoked considering radiological and clinical presentation. So, non-operative management was decided. The patient was put under close medical surveillance with good clinical and biological evolution.
3. Discussion
Pneumoperitoneum is a surgical emergency in 90% of cases, and in the remaining 10% of cases, pneumoperitoneum is due to non-surgical causes [1] [2]. The diagnosis is difficult given the difficulty to exclude an intestinal perforation. The absence of fever and abdominal tenderness or guarding should be associated with the absence of a significant biological infectious syndrome, and with the absence of intraperitoneal effusion, or the enhancement of the peritoneal layers on the radiological findings to exclude an intetinal perforation [4] [5].
The causes of spontaneous pneumoperitoneum are variable and multiple. It can be due to thoracic, abdominal, or iatrogenic origin. Gynecological origin and idiopathic origin are also evoked [1] [2] [4] [5]. The intrathoracic causes are dominated by: traumatic pneumothorax, barotrauma, broncho-peritoneal fistulas, severe destructive lesions of the parenchyma (pneumonia, malignant lesion), mechanical ventilation in Positive Pressure (PEEP) with possible coexistence of a pneumo-mediastinum and pneumopericardium, resuscitation maneuvers; the diffusion of gas from the alveoli into the peribronchovasular interstitium allows them to reach the mediastinum and then the retroperitoneum via the peri-aortic and peri-oesophageal interstitium [5] [6]. Abdominal causes are mainly represented by chronic intestinal cystic pneumatosis, where the pneumoperitoneum can be massive and recurrent. Subclinical perforation of a hollow viscus can induce a pneumoperitoneum. Some perforations heal, seal and only allow a small amount of gas to escape, without having infectious consequences [2] [5].
The gynecological origin is explained by vaginal insufflations, knee-chest exercises in the postpartum, inflammatory diseases of the pelvis, coitus, and high pressure vaginal douching [1] [2].
After gastrointestinal endoscopy, a persistent pneumoperitoneum may occur. The duration of this iatrogenic pneumoperitoneum varies between 7 days and 21 days according to some publications. Gynecological examination and vaginal diagnostic and therapeutic techniques can also lead to pneumoperitoneum [2].
In certain situations, the pneumoperitoneum will be qualified as idiopathic, when the etiological assessment returns negative, excluding other causes of pneumoperitoneum [3].
Through this case, and in front of a pneumoperitoneum, we emphasize the importance of history and a thorough physical examination and the appropriate paraclinical examinations to identify the non-surgical pneumoperitoneum and to avoid an unnecessary laparotomy by choosing a conservative treatment, and adopting rigorous and close monitoring, so as not to miss a surgical emergency.
4. Conclusion
Spontaneous pneumoperitoneum should be well-known, even if it remains rare, because it exposes to unnecessary surgical interventions, in front of the possibility of an applicable conservative approach and requires a well-directed investigation of the possible causes.