Benign Pneumoperitoneum Research Articles

Endoscopy-induced complication of barotrauma with concomitant benign pneumoperitoneum

Endoscopy-induced complication of barotrauma with concomitant benign pneumoperitoneum

Neonatal Benign Pneumoperitoneum: Three Case Reports and Review of The Literature

Introduction: Neonatal benign pneumoperitoneum (NBPP) is an uncommon condition often characterized by abdominal distension. It necessitates differential diagnosis to distinguish it from pneumoperitoneum caused by perforation and peritonitis, which may lead to an exploratory laparotomy with negative outcomes. In this document, we summarize the cases of NBPP treated at our hospital over the past decade and review relevant literature to offer insights into the diagnosis and treatment of this disease. Case Presentation: We report on three cases of NBPP, all of which presented with abdominal distension. Two of the cases were managed conservatively, while one underwent exploratory laparotomy. No evidence of perforation or other significant findings was observed during the surgery. All three patients survived. Conclusions: In cases of suspected neonatal pneumoperitoneum, it is essential to consider NBPP as a differential diagnosis and closely monitor disease progression to prevent misdiagnosis. NBPP can often be managed conservatively, although it is crucial to vigilantly observe any changes in vital signs throughout the treatment. Further research is needed to elucidate the etiology and pathogenesis of this disease.

Diagnosis, risk factors, and treatment of pediatric benign pneumoperitoneum: A single‐center retrospective study

AbstractPneumoperitoneum is one of the common acute abdominal emergencies that leads to surgical exploration in children, but not all pneumoperitoneum require emergency surgery. This study evaluated the diagnostic methods, predisposing risk factors, and therapeutic options in children with benign pneumoperitoneum for accurate diagnosis and reducing the risk of adverse surgical consequences. A total of 63 cases of pneumoperitoneum diagnosed by the radiographs were involved in this study and were divided into the surgical pneumoperitoneum and benign pneumoperitoneum groups, respectively, from 2009 to 2021. The general information, abdominal signs, laboratory examination, therapies and outcomes, total hospitalization time, and comorbidities were analyzed. Logistic regression analysis assessed the risk factors and protective factors of benign pneumoperitoneum. Promising biomarkers underwent receiver operating characteristic curve analysis. Children with surgical pneumoperitoneum were younger than those with nonsurgical pneumoperitoneum in the study. The C‐reactive protein (CRP) level in the surgical pneumoperitoneum group was higher than that in the other group, albumin (ALB) was lower than that in the benign pneumoperitoneum group, and the ratio of ALB to CRP can be used as an effective indicator to predict whether the pneumoperitoneum is benign or whether surgery is needed. Pulmonary injury, pneumonia, and blunt abdominal injury are the major causes in patients with benign pneumoperitoneum. The establishment and management of clinical criteria for the diagnosis of benign pneumoperitoneum in children will be important for the treatment and recovery of children diagnosed with pneumoperitoneum.

S3691 Where Is the Bumper? A Case of Percutaneous Endoscopic Gastrostomy (PEG) Tube Malfunction

Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes are used for enteral access in patients requiring nutritional support. PEG tube placement and removal generally are regarded as safe procedures. However, complications can be experienced in 16-70%, ranging from benign pneumoperitoneum to gastric outlet obstruction, buried bumper syndrome, and bowel perforation. Our case describes a retained internal bumper during PEG tube removal that undergoes spontaneous passage. Case Description/Methods: Our patient is a 71-year-old male with a past medical history of tongue cancer treated with chemoradiation and subsequent dysphagia due to esophageal strictures necessitating PEG tube placement. He presented to the hospital with nausea, recurrent emesis, and an inability to tolerate tube feeds. His PEG tube was placed to gravity with one liter of output and relief of symptoms. A plan was made to proceed with gastrojejunostomy (G-J) tube to mitigate his symptoms. During bedside removal of his PEG tube, the internal bumper was noted to no longer be attached to the tube (Figure 1A). A Foley catheter was placed in the tract to maintain its patency. As the bumper was presumed to be retained in the stomach, esophagogastroduodenoscopy was performed but there was no evidence of foreign body throughout the exam. A computed tomography scan of his abdomen was obtained urgently and showed passage of the bumper into the jejunum (Figure 1B). Serial abdominal radiographs were obtained over the following day showing migration of the bumper into the rectum and was subsequently passed in his stool. Thereafter, the patient has successfully G-J tube placement by interventional radiology. His tube feeds were advanced to goal rate and the patient was no longer having any nausea or vomiting. Discussion: Retained PEG tube internal bumper is a rare complication of PEG tube removal. Prior case reports have described bumper migration into the small bowel where it became lodged and resulted in small bowel obstruction. At least one prior case resulted in small bowel perforation. In cases of bowel obstruction, surgical intervention is warranted. However, in most cases this complication simply warrants clinical monitoring for evidence of obstruction or passage of the PEG bumper; in most reported cases, endoscopic retrieval was not attempted or feasible, and resolved via spontaneous bumper passage through the gastrointestinal tract.Figure 1.: (A) PEG tube with internal bumper no longer attached. (B) CT scan of abdomen showing PEG tube bumper in the jejunum (orange arrow).

S2848 Massive Pseudo-Pneumoperitoneum After Endoscopic Necrosectomy

Introduction: Encapsulated peripancreatic fluid collection and walled-off necrosis are some of the complications of acute pancreatitis. Most resolve spontaneously but symptomatic pseudocysts or walled-off necrosis require drainage. The preferred therapeutic management is endoscopic ultrasound (EUS) guided drainage with stent placement. Known iatrogenic complications of the procedure include bleeding and perforation. Case Description/Methods: A 39-year-old woman with history of ulcerative colitis, in remission on certrolizumab presented with symptomatic walled-off necrosis after idiopathic necrotizing pancreatitis. EUS-guided drainage and stent placement was successfully performed. On subsequent upper endoscopy for necrosectomy, post-procedure large pneumoperitoneum was noted on imaging leading to emergent surgical evaluation with laparoscopy. However, no perforation or pancreatic fluid contamination was seen. On post-operative day 1, patient was asymptomatic and tolerating diet. She was discharged on post-operative day 2. At 3-month follow-up, patient remained asymptomatic and plastic stents were removed. Discussion: Pneumoperitoneum is an uncommon but dreaded complication of EUS guided cystogastrostomy. This occurs when there is separation of the gastric wall and the wall of the pancreatic cyst or walled-off necrosis. If perforation is detected during cystgastrostomy, it may be possible to use a LAMS to close the defect by bridging the walls or close the gastric defect endoscopically with clips or sutures. Immediate surgery (such as cyst-enterotomy with closure of the wall defect) should be performed if there is generalized contamination of the peritoneum with cyst fluid content and subsequent signs of peritonitis. (Figure) Our case, to our knowledge, is the only one that describes pneumoperitoneum after endoscopic necrosectomy, two weeks after placement of LAMS. Our hypothesis is that the walled-off necrosis moved away from the gastric wall after removal of LAMS, which had aided apposition of the gastric wall and cyst wall due to its flanges and short saddle length. Pneumoperitoneum, in the absence of peritoneal findings, is referred to as benign peritoneum. Our case describes massive benign pneumoperitoneum after endoscopic necrosectomy without perforation. There is a paucity of literature on non-surgical management of post-endoscopic pneumoperitoneum and we hope that our case, will help endoscopists carefully select patients who will benefit from surgical management of pneumoperitoneum.Figure 1.: Figure A. CT abdomen showing pancreatic walled off necrosis containing turbid fluid and debris. Figure B. Massive pneumoperitoneum seen on CT abdomen after EUS-guided drainage and double pig-tailed stent placement for continued drainage.

Spontaneous pneumoperitoneum in neonates: a case series

BackgroundPneumoperitoneum is defined as the presence of free air in the peritoneal cavity. It is a surgical emergency that represents in 90% of the cases with a hollow viscus perforation and its feared consequences of sepsis and death. On the other hand, spontaneous pneumoperitoneum is a benign surgical entity occurring in newborns that requires no surgical intervention.Cases presentationIn this series, we report three cases of benign spontaneous pneumoperitoneum in neonates treated at Jordan University Hospital between 2004 and 2021. Two of them were treated by exploration laparotomy but no gross pathology could be identified; one case was successfully treated conservatively with observation alone.ConclusionThis case series recognizes the presence of such entity which can be treated conservatively, eliminating the unnecessary burden of morbidity and mortality of surgery in such age group.

Benigní asymptomatické pneumoperitoneum u pacientky po CT kolografi i

Pneumoperitoneum is a condition that refers to the presence of free air (gas) in the abdominal cavity. Differential diagnosis of the causes of pneumoperitoneum varies widely and represents varying degrees of severity. In the patients who have not recently underwent laparotomy or laparoscopy, the finding of pneumoperitoneum is usually a sign of gastrointestinal perforation that requires immediate surgical approach due to the risk of peritonitis with subsequent life-threatening sepsis. However, not all causes of pneumoperitoneum require surgery. In our case report, we present a rare case of clinically asymptomatic pneumoperitoneum that developed in a 66-year-old patient after CT colonography. In this diagnostic method, we inflate colon with carbon dioxide (CO2 ); therefore this kind of pneumoperitoneum can de facto be called capnoperitoneum. In this patient, free air (gas) in the abdominal cavity manifested itself in the so-called benign pneumoperitoneum, which is defined as asymptomatic free air in the abdominal cavity and pneumoperitoneum without peritonitis. Despite the fact that CT colonography is considered a method with a very low incidence of complications, it is necessary to take into account the presence of risk factors in its indication and to contraindicate to avoid the number of postoperative complications. The fundamental message of our case report is that extensive pneumoperitoneum after proven CT colonography can be asymptomatic and can be treated conservatively (if clinical and laboratory results are favorable).

Abstract No. 497 Necessity of imaging follow up to confirm gastrostomy tube position prior to use

To assess the value of obtaining routine next-day radiographic contrast tube study following placement of percutaneous push-type gastrostomy tubes From January 2015 to February 2020, all primary percutaneous push-type gastrostomy tube placement procedures have been identified. Demographic data, purpose of procedure (feeding versus venting), periprocedural (one month) complications, and results of next-day radiographic contrast tube studies (performed prior to initiation of tube feeding) were recorded. Retrospective review of procedural and next-day radiographic images of patients with abnormal tube studies was performed. A total of 267 procedures were identified. 261 patients received next-day radiographic contrast tube studies. 7 patients (2.6%) of those had abnormal studies with only 3 patients (1.2%) requiring surgical/interventional management. Tube studies revealed tube dislodgement in 3 patients, deflated balloon in one patient, false positive interpretation of extraluminal contrast in one study (ruled out by CT scan), and two cases of benign pneumoperitoneum. Retrospective review of the 3 patients with tube dislodgment revealed extraluminal tube placement evident on last archived fluoroscopic procedural images, not recognized during the procedure. 254 patients had normal post procedure tube study and of those; 3 cases were complicated by tube dislodgment (2 in day-2 and 1 in day-12 post procedure). Subsequent imaging for non–tube-related indications showed transhepatic tube placement in one patient and pneumoperitoneum in 12 patients (one with pneumatosis of the colon leading to negative surgical exploration). 6 patients did not receive next-day tube study; however, no periprocedural complications were encountered in this group. Routine use of radiographic contrast tube studies following primary placement of push-type gastrostomy tubes revealed tube mis-placement in few cases, all of which could have been detected intra-procedurally.

A Case of Idiopathic Diffuse Pneumoperitoneum Presented with Neonatal Abdominal Color Change

Background: Necrotizing enterocolitis is the leading cause of intestinal perforation and pneumoperitoneum in neonates. In addition, neonatal pneumoperitoneum includes several conditions requiring surgery, such as gastric and duodenal perforation, intestinal atresia, volvulus, meconium ileus, and Hirschsprungג��s disease. A type of pneumoperitoneum in which intra-abdominal free air is detected through direct X-ray; however, no cause is found clinically and radiologically during the surgery is named ג��benign pneumoperitoneumג��. Case report: This case report presents a 5-day-old male newborn who is presented with complaints of abdominal color change and vomiting and is diagnosed with Idiopathic Benign Pneumoperitoneum (IBP) during the operation. Neonatal pneumoperitoneum usually occurs as a result of perforation and requires emergency surgery. Rare cases of IBP should also be kept in mind. Unnecessary surgery can be prevented by establishing a differential diagnosis with clinical, laboratory, and imaging methods.  Conclusion: This case demonstrated that laparotomy is not a true routine in neonates with IBP if a timely diagnosis is established.

Pneumatosis intestinalis and pneumoperitoneum secondary to Sapovirus colitis

Pneumatosis intestinalis (PI) with pneumoperitoneum are radiographic findings that may be associated with severe bowel compromise. Asymptomatic patients with benign pneumoperitoneum are well described and can typically be observed. Among symptomatic patients, these findings are more concerning and often mandate operative intervention. The common etiologies of PI with pneumoperitoneum in children can typically be determined by history, physical and imaging findings. Viral enteritis and colitis is an infrequent cause. Sapovirus is in the family Caliciviridae . It is similar to norovirus, a more common pathogen in acute gastroenteritis, but typically presents with less severe symptoms. Here, we describe the presentation of an 11 year old, immune competent boy with severe abdominal pain, PI and pneumoperitoneum. Diagnostic laparoscopy revealed viable bowel without the need for resection or diversion. Stool pathogen panel revealed Sapovirus infection. He made a complete recovery. To our knowledge, this is the first description of PI with pneumoperitoneum caused by Sapovirus infection. • To our knowledge, the first description of pneumatosis intestinalis and pneumoperitoneum from Sapovirus infection. • A helpful description of Sapovirus, a common, but mostly innocuous cause of mild acute gastroenteritis. • A useful review of the interpretation and management of pneumatosis intestinalis and pneumoperitoneum in children. • Successful use of laparoscopy to confirm bowel viability in the setting of a worrisome abdominal exam and imaging.

A Rare Care of Subcutaneous Emphysema After Colonoscopy with No Identifiable Mucosal Defect

We present an interesting case of subcutaneous emphysema after colonoscopy with near-obstructing mass noted at the hepatic flexure in an overall healthy 91-year-old female. Our patient was a healthy 91-year-old woman who presented with one week of right lower abdominal pain that started after a fall. CT scan of the abdomen revealed an indeterminate lesion at the cecum. A colonoscopy was performed for further evaluation and demonstrated a near obstructing lesion at the hepatic flexure that could not be traversed with the colonoscope. Biopsies were taken and the area was tattooed. After outpatient discharge following the colonoscopy, the patient re-presented to the emergency room with complaint of abdominal distention. While in the hospital she developed subcutaneous crepitus in the neck and face. Subsequent imaging revealed a large amount of subcutaneous air and findings consistent with pneumoperitoneum. She was hemodynamically stable, however given the concern for possible perforated viscus post-colonoscopy, the patient was urgently taken the operating room for an exploratory laparotomy and right-sided hemicolectomy. During surgery no full thickness tear of the colon was visualized. No defect was identified in colonic mucosa by pathology. It was only notable for adenocarcinoma. Subcutaneous face and neck emphysema is a rare complication after colonoscopy. The vast majority of cases of subcutaneous emphysema following colonoscopy in the literature are postulated to be secondary to colonic perforation and have been managed successfully with nonoperative treatment. Our case is unique in that our patient was taken to the operating room due to the obstructive lesion found, yet thorough examination of the colon intraoperatively and by pathology demonstrated no frank evidence of colonic perforation. Another interesting part of the case is the use of India ink tattooing of the obstructing lesion during the index colonoscopy to mark the lesion, which has also rarely been reported in the literature as a cause of occult perforation. Finally, the patient in our case could have been presenting with benign pneumoperitoneum found incidentally on imaging that were unrelated to her complaints of abdominal distension. While also uncommon in the literature, authors have recommended treating all cases of potentially benign pneumoperitoneum as perforations nonetheless, a practice that was followed in this patient's care. The patient recovered uneventfully.1576_A Figure 1. Stricture at hepatic flexure noted during colonoscopy1576_B Figure 2. Right eye crepitus1576_C Figure 3. Gross specimen

Cystic intestinal pneumatosis revealed by peritonitis in perforated peptic ulcer: A case report

Cystic intestinal pneumatosis is a rare condition characterized by the presence of cyst-like formations in the walls of the digestive tract. Cystic intestinal pneumatosis can affect any part of the digestive tract. However, the small and large bowels are the most affected. This pathology is more common in men and after the age of 50 years. Cystic pneumatosis of the intestines may be idiopathic or most often secondary to various diseases. The primitive forms preferentially affect the left colon with essentially submucous gaseous cysts, whereas the secondary intestinal cystic pneumatosis tend to affect the small intestines especially in the subserosa. The origin of this pathology is multifactorial but the main cause is not definitively proven. The long list of pathological associations has led to the development of various etiopathogenic theories that are not antinomic since some mechanisms may be associated.Cystic intestinal pneumatosis is most often asymptomatic and therefore fortuitously discovered. This pathology could have clinical signs like bloody and glairy stools, abdominal pain, and diarrhea. Endoscopic and radiological examinations are easy to diagnose and avoid unnecessary laparotomy explorations in benign pneumoperitoneum. Treatment varies according to its etiology. For primary forms, antibiotic therapy to reduce the hydrogen-producing colonic flora is indicated as first-line treatment. If unsuccessful, oxygen mask or hyperbaric, which will promote the replacement of hydrogen with oxygen, must be attempted. For secondary forms, the treatment is that of the causal affection. In most cases, cystic intestinal pneumatosis is asymptomatic and no treatment is needed. Surgery remains reserved for serious forms of this disease.

Diagnosis and treatment of pediatric benign pneumoperitoneum: A case report series of 9 patients.

Introduction:Benign pneumoperitoneum (BPPT) is defined as asymptomatic free intraabdominal air or as pneumoperitoneum without peritonitis. Symptomatic free air requires surgical anagement, but management of asymptomatic pneumoperitoneum is controversial. In this study, we investigate the diagnosis and treatment of BPPT in children.Clinical Findings:The clinical data of 9 pediatric patients with BPPT who were admitted to our hospital from January 2000 to January 2015 were retrospectively analyzed to summarize the diagnosis and treatment. Overall, 9 cases were included with 8 males and 1 female, aged from 4 days to 4 years. Among them there were 6 newborns (including 1 premature infant). Patients were all admitted to hospital with the major clinical symptom of abdominal distension, including 2 cases accompanied by tachypnea, 2 cases with vomiting, 1 case with diarrhea, and 2 cases with fever. No previous constipation or obstructive defecation existed. Six newborns had meconium defecation within 24 hours after birth. Physical examination revealed all patients with relaxed abdominal wall except 1 patient with abdominal distension had slight muscle stiffness and hyperactive bowel sounds. Abdominal X-ray suggested free air under the diaphragm in all cases.Interventions/Outcomes:All patients except for one case of laparotomy were conservatively treated and cured with fasting, infection prevention, rehydration, abdominocentesis, and close observation. Nine cases of patients were all discharged with no death occurrence. After discharge follow-up of 7 months to 6 years was conducted. There was no recurrence of similar symptoms, and children were in good growth and development.Conclusion:The diagnosis of BPPT mainly relies on clinical symptoms in patient, careful abdominal examination, abdominal X-ray combined with abdominocentesis, and the exclusion of gastrointestinal perforation for confirmation. Conservative treatment can cure the disease. Attention should be paid to distinguish with surgical pneumoperitoneum to avoid unnecessary surgical exploration.

Chronic Benign Pneumoperitoneum

Introduction: Pneumoperitoneum is encountered in the setting of perforation of a hollow viscus in over 90 percent of cases.1 A perforated ulcer is the most common cause, followed by iatrogenic interventions2. Case: We report a 78 year old Caucasian male with atrial fibrillation, prostate cancer, asymptomatic cholelithiasis, diverticulosis with prior diverticulitis and osteoarthritis who underwent a CT of his chest to evaluate a pulmonary nodule in 2011, with the incidental discovery of intraperitoneal free air. He had not had previous abdominal/surgical interventions that could cause a pneumoperitoneum and a CT obtained a year ago was negative for intraperitoneal free air. Physical exam showed him to be afebrile, alert and oriented with clear lungs and a non-tender abdomen. A follow up CT of his abdomen with contrast was performed noting multifocal intraperitoneal free air with extensive diverticular disease. Four years later a chest x-ray was obtained prior to knee replacement surgery and again, air was present under the diaphragm, leading to another CT of his abdomen. Similar to the prior CT scan, pneumatosis in a short segment of small bowel in the right mid to upper quadrant without any wall thickening or surrounding stranding was identified. He remains without abdominal symptoms. Discussion: Pneumoperitoneum generally elicits an urgent surgical evaluation and can require operation. An uncommon cause of pneumoperitoneum is intestinal pneumatosis which consists of gas located in the bowel wall, whatever the cause or location. It can occur idiopathically (primary form in 15 % cases) or secondarily in 85 % of cases3. Pneumatosis cystoides intestinalis (PCI) is another rare disease characterized by the presence of gaseous cysts in the intestinal wall. Rupture of PCI can also lead to pneumoperitoneum4. Chandler et al report a laparotomy rate of 28 % for patients with pneumoperitoneum without overt peritoneal signs5. We often encounter the same diagnostic and management dilemma in patients free of peritoneal signs. A complete history and physical are important for further evaluation of a benign pneumoperitoneum and avoidance of unnecessary laparotomy. Additionally, CT scanning, especially with the use of oral and/or rectal contrast is very sensitive in detecting even tiny visceral perforations. This case is unusual due to the absence of symptoms, lack of a surgical history and the incidental discovery of intraperitoneal air and intestinal pneumatosis during a preoperative risk assessment, with similar findings four years earlier.Figure 1

Massive Retro-Pneumoperitoneum and Lower Limb Subcutaneous Emphysema After Pediatric Heart Transplantation: A Case Report

An emphysema in a lower limb is usually a clinical sign of a severe and life-threatening infection. We report a rare case of subcutaneous emphysema of the left lower limb associated with a massive retro-pneumoperitoneum and pneumatosis intestinalis after cardiac transplantation in a 4-year-old girl. The child was nearly asymptomatic beside an abdominal distension. A benign pneumoperitoneum associated with an extensive pneumatosis intestinalis is a rare complication after organ transplantation and should be treated conservatively. The association with an emphysema in a lower limb in a child has not been previously reported to our knowledge in the literature.

Benign pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG) feeding tube placement: do not be afraid!

In order to ensure enteral feeding, placement of a percutaneous endoscopic gastrostomy (PEG) is considered a standard care for patients with oropharyngeal malignancies. Benign pneumoperitoneum is a complication of PEG feeding tube placement and it is usually an incidental finding that arises, generally, immediately following the procedure. We report a case of a benign pneumoperitoneum, developed 48 hours after the procedure, which was treated conservatively.

Gastrointestinal and Hepatic Manifestations of Systemic Lupus Erythematosus

In this review of the gastrointestinal (GI) and hepatic manifestations of systemic lupus erythematosus (SLE), 180 articles from the English literature, found using a medline search from January 1965 to December 2010, were examined. Vasculitis may cause ulcerations, bleeding, stricture formation, and perforation from ischemia and infarction. Otherwise, GI symptoms, occurring in about 50% of patients, are usually mild. Esophageal dysmotility may result in heartburn, regurgitation, and dysphagia. Occasionally, pneumatosis cystoides intestinalis may develop, sometimes associated with benign pneumoperitoneum. Patients are prone to salmonella bacteremia, presenting more commonly with fever and abdominal pain than with diarrhea. Intestinal pseudoobstruction usually is found with active lupus serology, preferentially involving small rather than the large bowel. Protein-losing enteropathy, characterized by diarrhea, edema, and hypoalbuminemia, can be the initial presentation of SLE. Malabsorption with a prevalence of 9.5% is occasionally associated with celiac disease. Pancreatitis, with an annual incidence of 0.4 to 1/1000, has an overall mortality of 27% that is decreased with corticosteroid therapy. Acute and chronic ascites may be due to lupus peritonitis or to associated diseases, such as pancreatitis, nephrotic syndrome, heart failure, or infections. Abnormal liver function tests may be due to steatosis from lupus or from corticosteroid therapy. Only about 10% of patients with autoimmune hepatitis have lupus. Up to 4.7% of patients with SLE have chronic active hepatitis correlating strongly with the presence of antibody to ribosomal P protein. SLE can involve the entire GI tract and the liver. Treatment with corticosteroids, cytotoxic agents, and/or immunosuppressants is often successful.

Benign Spontaneous Pneumoperitoneum in Systemic Sclerosis

The gastrointestinal tract is commonly involved in patients with systemic sclerosis (SSc) (Am J Gastroenterol. 1972;58:30-44). Intestinal manifestations of SSc include impaired motility, malabsorption, bacterial overgrowth, jejunal and wide-mouthed colonic diverticuli, localized dilatation, pseudo-obstruction, and, less commonly, pneumatosis cystoides intestinalis (PCI) (Rheumatology. 2009;48:iii36-iii39; J Clin Gastroenterol. 2008;42:5-12). Benign spontaneous pneumoperitoneum is a rare complication of SSc and is often associated with PCI (Mo Med. 1967;64:117-118). We report a case of spontaneous pneumoperitoneum without evidence of peritoneal irritation in a malnourished patient with long-standing SSc. Computed tomography scan of the abdomen and pelvis on admission revealed pneumoperitoneum with PCI without visceral perforation. Subsequent imaging revealed the persistence of the pneumoperitoneum with resolution of the PCI. It is important for the clinician to recognize benign spontaneous pneumoperitoneum as a possible complication in patients with SSc and to be able to differentiate this from a ruptured viscus with peritonitis based on clinical presentation. The management of benign spontaneous pneumoperitoneum is supportive, thereby avoiding unnecessary surgery.

Benign Pneumoperitoneum after Colonoscopy

Pneumoperitoneum frequently indicates a perforated abdominal viscus that requires emergent surgical management. However; pneumoperitoneum, on rare occasion, can occur without perforation. In these cases, it is defined as benign pneumoperitoneum. Benign pneumoperitoneum means asymptomatic free intra-abdominal air or pneumoperitoneum without peritonitis and can occur occasionally with colonoscopy. In this paper, we present a rare case of benign pneumoperitoneum that developed after diagnostic colonoscopy and review it in conjunction with the current literature.

Combined Epidural Emphysema and Nonsurgical Pneumoperitoneum After Blunt Trauma: Report of Two Cases and Review of the Literature

Epidural emphysema is a rare condition, and when occurs in isolation it is usually benign and resolves spontaneously after the underlying cause has been treated. Epidural emphysema is usually accompanied by pneumothorax, subcutaneous emphysema, or pneumomediastinum. In addition, nonsurgical (benign) pneumoperitoneum is a state of the presence of air in the peritoneal space, not requiring surgical intervention. Although nonsurgical pneumoperitoneum can arise in different ways, generally pneumomediastinum or pneumothorax is observed in cases with an intrathoracic source. We report two cases of combined traumatic epidural emphysema and nonsurgical pneumoperitoneum in patients with pneumothorax, pneumomediastinum, and extensive subcutaneous emphysema after blunt trauma.