Recurring spontaneous aseptic pneumoperitoneum presenting secondary to an unrelated chief complaint: A case report

Abstract

Introduction: Pneumoperitoneum, observed by radiography, is typically associated with the perforation of hollow viscous. More than 90% of all cases of pneumoperitoneum are the result of a gastrointestinal tract perforation. These patients usually present with signs of acute peritonitis and require immediate surgical exploration and intervention. However, rare cases of idiopathic spontaneous pneumoperitoneum do occur without any indication of visceral perforation and other known causes of the free intraperitoneal gas.

Presentation of case: A 66-year-old male presented to the emergency department on three separate occasions with similar episodes six months apart. Upon physical examination and subsequent testing, chest radiography revealed the presence of free intraperitoneal gas. A computerized tomography (CT) was performed in which pneumatosis and pneumoperitoneum was reported with the first two admissions and both laparotomies were negative. This patient continues to be followed for prostate cancer and bony metastases. All subsequent CT scans (last performed 01/2014) have shown no acute or chronic abdominal pathology and no obstructions. He also had upper and lower endoscopies in 2011, which were negative.

Discussion: This case revealed very different finding than anticipated. The patient presented to the emergency department with symptoms unrelated to the CT findings of free intraperitoneal gas. On two separate occasions, the patient underwent a laparotomy with negative findings. The conventional course of treatment for pneumoperitoneum was followed, but was it necessary? Though the presentation of pneumoperitoneum is most often associated with significant pathology requiring surgical intervention, a more conservative approach may be applicable in cases similar to the one presented here.

Keywords: Air under diaphragm; Pneumatosis cystoides intestinalis; Spontaneous pneumoperitoneum.

Fig. 1

Chest radiography July, 2011. Aseptic spontaneous pneumoperitoneum of unknown origin discovered during routine physical examination.

Fig. 2

Abdominal CT scan July 2011 confirming pneumoperitoneum.

Fig. 3

Chest radiography completed March 2012 during emergency department work-up. Results determined free intraperitoneal gas.

Fig. 4

Abdominal CT March 2012. Confirming pneumoperitoneum and pneumatosis of small bowel.

Fig. 5

Photograph taken during March 2012 laparotomy.