Spontaneous idiopathic pneumoperitoneum presenting as an acute abdomen: a case report

Abstract

Introduction: Pneumoperitoneum is most commonly the result of a visceral perforation and usually presents with signs of acute peritonitis requiring an urgent surgical intervention. Non-surgical spontaneous pneumoperitoneum (not associated with a perforated viscus) is an uncommon entity related to intrathoracic, intra-abdominal, gynecologic, iatrogenic and other miscellaneous causes, and is usually managed conservatively. Idiopathic spontaneous pneumoperitoneum is an even more rare condition from which both perforation of an intra-abdominal viscus and other known causes of free intraperitoneal gas have been excluded.

Case presentation: We present the case of an idiopathic spontaneous pneumoperitoneum. A 69-year-old Greek woman presented with acute abdominal pain, fever and vomiting. Diffuse abdominal tenderness on deep palpation without any other signs of peritonitis was found during physical examination, and laboratory investigations revealed leukocytosis and intraperitoneal air below the diaphragm bilaterally. Her medical history was unremarkable except for previous cholecystectomy and appendectomy. The patient did not take any medication, and she was not a smoker or an alcohol consumer. Emergency laparotomy was performed, but no identifiable cause was found. A remarkable improvement was noticed, and the patient was discharged on the seventh postoperative day, although the cause of pneumoperitoneum remained obscure.

Conclusion: A thorough history and physical examination combined with the appropriate laboratory tests and radiologic techniques are useful tools in identifying patients with non-surgical pneumoperitoneum and avoiding unnecessary operations.

Figure 1

Upright posteroanterior chest radiograph. There is free subdiaphragmatic air bilaterally that is more clearly noted on the right side (white arrows).

Figure 2

Upright posteroanterior chest radiograph after insufflating air into the stomach. The free subdiaphragmatic air has slightly increased in size bilaterally compared with Figure 1 (white arrows).

Figure 3

Upright posteroanterior chest radiograph just before the patient's discharge. No subdiaphragmatic free air is noted bilaterally.