Abstract
Pneumoperitoneum is described as the presence of free air in the peritoneal cavity. In the majority of cases, it is the manifestation of abdominal viscus perforation, requiring an emergent surgical exploration. In rare cases, however, no evidence of perforation of the gastrointestinal or genitourinary tracts can be found at exploration, and in such cases, the pneumoperitoneum is referred to as non-surgical pneumoperitoneum. We present a case of an 87-year-old man who developed a non-surgical pneumoperitoneum in the setting of gram-negative sepsis. The patient was admitted for treatment of obstructive uropathy and sepsis secondary to a gram-negative urinary tract infection. Despite the initial resuscitation and antibiotic therapy, his hospital course was complicated by worsening abdominal discomfort, and a chest radiograph revealed free air under the diaphragm. He was taken to the operating room for an emergent surgical exploration that revealed no visceral perforation or other possible surgical causes. He tolerated and recovered from surgery well, and had a complete resolution of pneumoperitoneum in the early post-surgery period, per radiographic imaging. This interesting case highlights a rare case of idiopathic nonsurgical pneumoperitoneum in the setting of gram-negative sepsis. Additionally, we discuss considering non-surgical etiologies for patients without clinical signs or surgical evidence of perforation.
Highlights
Pneumoperitoneum, described as the presence of free air in the peritoneal cavity, generally mandates emergent surgical exploration in the majority of cases [1,2]
We present a case of an 87-year-old man who developed a non-surgical pneumoperitoneum in the setting of gram-negative sepsis
We present a case of non-surgical pneumoperitoneum in the setting of gram-negative septicemia
Summary
Pneumoperitoneum, described as the presence of free air in the peritoneal cavity, generally mandates emergent surgical exploration in the majority of cases [1,2]. The patient had a history of lower abdominal pain for last two weeks He visited his primary care physician and underwent a computed tomography (CT) scan of the abdomen and pelvis which showed hypertrophy of the prostate and bilateral hydronephrosis. No acute cardiopulmonary changes were visualized on chest X-ray taken three days prior (Figure 1). Radiologic upright film of the chest demonstrates right-sided, free intraperitoneal air (red arrow). The patient underwent emergent exploratory laparoscopy that was converted to laparotomy, as there was no evidence of a perforation visualized on laparoscopy. Meticulous examination of the abdominal cavity revealed no evidence of an intestinal or genitourinary tract perforation or any other surgical causes, peritonitis, free fluid, or abscess formation.
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