Massive pneumopritoneum with no evidence of hollow viscus perforation, a possible hepatobiliary source; a case report

Abstract

Presenter: kiarash Mashayekhi MD,MS | San Joaquin General Hospital Background: Pneumoperitoneum is most frequently caused by hollow viscous perforation, which in most cases requires an exploratory laparotomy. In the event where no perforation can be identified, one must consider other rare causes of pneumoperitoneum. Methods: We report a case of a woman who presented to the emergency department with severe abdominal pain and nausea. Results: On initial exam the patient had peritonitis, and the CT of her abdomen & pelvis showed a substantial pneumoperitoneum, with a dilated cecum and ascending colon, and gallstones within a distended gallbladder. Initial exploratory laparotomy showed no hollow viscus perforation, an unroofed left liver lobe abscess, and a distended gallbladder. Further imaging after the initial operation showed significant choledocholithiasis, although her hepatic function tests remained normal. Subsequently the patient underwent ERCP, sphincterotomy, multiple stone extraction and stent placement. Two further exploratory laparotomies were performed for cholecystectomy and drainage of liver abscess, again with no identifiable hollow viscus perforation. Cultures drawn from the peritoneal fluid and abscess grew gas-forming organisms, prominently Klebsiella Pneumoniae. Over the next few weeks the patient decompensated and developed septic shock, and multi organ failure in spite of maximal therapy; she ultimately died from septic shock due to overwhelming hepatic and intraperitoneal abscesses. Conclusion: This case highlights a very uncommon etiology for pneumoperitoneum in the absence of hollow viscus perforation, from the hepatobiliary tract, associated with ascending cholangitis from an invasive form of Klebsiella Pneumoniae liver abscess syndrome.