Spontaneous pneumoperitoneum in appendicitis.

Abstract

Spontaneous pneumoperitoneum is infrequently encountered as a radiographic finding in association with a perforated appendix. This has led some authors to doubt that it occurs at all (11, 13). A review of the literature revealed a total of 10 cases reported by Vaughan and Singer (14), Guillemin (6), Kornblum (8), Spensley et al. (12), and Epstein (3). In most instances free intraperitoneal gas is a result of perforation of a peptic ulcer. The radiologist should, however, be aware of its occurrence in appendicitis with perforation in order not to mislead the surgeon. The present report describes 2 cases and discusses the pathogenesis as well as the reasons for the low incidence of this complication. Case Reports Case I: J. W. W., a 59-year-old white male, gave a history of abdominal pain, at first periumbilical, then migrating to the left lower quadrant and gradually spreading across the entire lower abdomen. He was first hospitalized and treated with penicillin at a private hospital, where a diagnosis of ruptured peptic ulcer or perforated appendix was made. He appeared acutely ill; blood pressure 120/80. On admission to the VA Hospital, three days after onset, there was tenderness in all quadrants of the abdomen, most pronounced in the right lower quadrant. There was mild rebound tenderness. The bowel sounds were hypoactive. The white cell count was 16,900, with 95 per cent neutrophils; red cell count 4,550,000. Films of the abdomen (Fig. 1) revealed a small amount of free peritoneal air consistent with a perforated viscus. Shortly after admission a diagnosis of ruptured viscus was made, the possibilities of ruptured sigmoid diverticulum, ruptured peptic ulcer, and ruptured appendix being considered. The patient was taken to surgery and a left McBurney's incision was made. On opening the peritoneum, a little air escaped. A large amount of moderately thick, yellowish-brown fluid was aspirated. The sigmoid colon was free of disease. The incision was closed and a right rectus incision was made. The stomach and duodenum appeared normal, but on exploration of the appendiceal area an abscess was found. A necrotic appendix was identified and removed. Culture from the abdominal cavity revealed E. coli. Postoperatively a fecal fistula developed, which gradually improved spontaneously. Case II: B. B., a 56-year-old white male, gave a history of the onset of epigastric pain, which shifted to the right lower quadrant, about three weeks prior to admission. He was at first treated conservatively by a private physician. After about one week he noted a tender mass in the right lower abdomen. There had been frequent attacks of right lower quadrant pain during the preceding year, usually disappearing within twenty-four hours. His blood pressure was 110/60; pulse 90; temperature 100.2°. He appeared chronically ill.