Recurrent spontaneous pneumoperitoneum: A surgical dilemma

Abstract

Introduction: Spontaneous pneumoperitoneum describes free air within the peritoneal cavity in the absence of iatrogenic causes or a perforated viscus. This report describes a rare case in which despite raised inflammatory markers, a trial of conservative management proved adequate.

Case report: AM is a 36-year old woman who presented multiple times with abdominal pain and radiologically proven pneumoperitoneum. Her medical history included self catheterisation and cerebrovascular stenosis (Moyamoya disease), asymptomatic gallstones, livedo reticularis and peptic ulceration. On her index admission she exhibited raised inflammatory markers and fever. Despite these findings, emboldened by similar presentations in the past with no cause found, she declined surgical intervention with no untoward consequences.

Discussion: Most patients presenting with non-surgically induced pneumpoeritoneum display signs of peritonism including pyrexia and raised inflammatory markers. For such patients, surgical intervention is usually required to find and rectify the cause.

Conclusion: A trial of conservative management may be appropriate in patients with spontaneous pneumoperitoneum but it must always be borne in mind that clinical deterioration represents an indication for surgical intervention.

Keywords: Conservative management; Inflammatory markers; Spontaneous pneumoperitoneum.

Fig. 1

Barium Small Bowel Meal and Follow Through showing normal small and large bowel.

Fig. 2

Axial view of CT scan showing free intraperitoneal gas anterior to the liver and stomach.