Free Intraperitoneal Air Research Articles

Gastrojejunal Anastomosis Perforation after Gastric Bypass on a Patient with Underlying Pancreatic Cancer: A Case Report and Review of the Literature.

Introduction. We describe a case of gastrojejunal anastomosis perforation after gastric bypass on a patient with underlying pancreatic cancer. Case Description. A 54-year-old female with past surgical history of gastric bypass for morbid obesity and recent diagnosis of unresectable pancreatic cancer presents with abdominal pain, peritonitis, and sepsis. Computerized axial tomography scan shows large amount of intraperitoneal free air. The gastric remnant is markedly distended and a large pancreatic head mass is seen. Intraoperative findings were consistent with a perforated ulcer located at the gastrojejunal anastomosis and a distended gastric remnant caused by a pancreatic mass invading and obstructing the second portion of the duodenum. The gastrojejunal perforation was repaired using an omental patch. A gastrostomy for decompression of the remnant was also performed. The patient had a satisfactory postoperative period and was discharged on day 7. Discussion. Perforation of the gastrojejunal anastomosis after Roux-en-Y gastric bypass is an unusual complication. There is no correlation between the perforation and the presence of pancreatic cancer. They represent two different conditions that coexisted. The presence of a gastrojejunal perforation made the surgeon aware of the advanced stage of the pancreatic cancer.

Hepatic Portal Venous Gas: Findings on Ultrasound and CT

A 76-year-old female with a history of Parkinson’s, dementia, and hypertension presented to the emergency department with non-bilious, non-bloody vomiting and abdominal pain for 2 days. Her exam was significant for borderline hypotension without tachycardia, abdominal distension and a palpable ventral hernia. An emergency physician performed ultrasound showed free intraperitoneal air and gas in the liver (Video). A computed tomography showed pneumoperitoneum, pneumatosis intestinalis, and hepatic portal venous gas (HPVG) (Figure). At laparotomy, she was found to have a sigmoid colon perforation from adenocarcinoma, ischemic small bowel, and a colovesicular fistula. Post-operatively her clinical status worsened, and she was transitioned to comfort care and expired on hospital day 2. Figure Computed tomography without contrast of the abdomen and pelvis showing free air (asterisks), pneumatosis intestinalis (thin arrows), and hepatic portal venous gas (large arrow). HPVG was first reported in infants with necrotizing enterocolitis.1 In adults, it is most commonly associated with mesenteric ischemia and pneumatosis intestinalis, accounting for 43% of HPGV cases2 and an associated mortality of 75%.2–3 It has been reported with other diseases such as diverticulitis, inflammatory bowel disease, obstructive pyelonephritis, pancreatitis, cholangitis, uterine gangrene, and severe shock.4 HPVG is attributed to either bacterial gas production in bowel entering mesenteric circulation4 or intraluminal air entering capillaries from impaired mucosal barrier or increased intraluminal pressure.5 HPVG spreads to the periphery of the liver whereas pneumobilia collects centrally, in the direction of bile flow. Treatment is always aimed at the underlying etiology of HPVG.

Emphysematous pyelonephritis masquerading as hollow viscus perforation

Introduction Emphysematous pyelonephritis (EPN) may be defined as a severe infection of the kidney that leads to necrosis and the presence of gas in the renal parenchyma, surrounding tissue, and the pelvi-calyceal system. EPN occurs almost exclusively in diabetics, but may occasionally complicate obstructive uropathy in non-diabetic patients. Case Report We present the case of a 45year old male with uncontrolled diabetes mellitus who presented with acute abdominal pain and free intraperitoneal air on abdominal radiograph, initially suggestive of hollow viscus perforation. He was found to have EPN that had ruptured into the peritoneal cavity. Conclusion Acute abdominal emergencies presenting with a pneumoperitoneum are not an uncommon occurrence in emergency centres throughout the world. However, rarely, patients present with the source of the pneumoperitoneum being an organ other than bowel. These patients need to be identified as soon as possible to prevent further morbidity and mortality arising from a delay in diagnosis.

Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: Experience from a community-based hospital

IntroductionComputed tomography (CT) scan has increasingly become the diagnostic modality of choice for the evaluation of patients with blunt abdominal trauma. CT scan is highly sensitive in the detection of small amounts of free intraperitoneal air (FIA). We aimed to evaluate the usefulness of FIA detected by CT scan in diagnosing bowel perforation in blunt trauma patients. Patients and methodsAll abdominal CT scans of blunt trauma patients who were treated at Al Rahba Hospital during the period from October 2010 till December 2013 were retrospectively reviewed. The results of abdominal CT scan were compared with the clinical follow up and operative findings to evaluate the sensitivity, specificity, predictive values, and usefulness index of CT-detected FIA in diagnosing bowel perforation. ResultsAbdominal CT scans were performed for 419 trauma patients. 21 (5%) patients were found to have FIA, two of them were true positive (10%), six (29%) needed mechanical ventilation, and eleven (52%) had a pneumothorax. 15/21 (71%) patients had multiple FIA pockets; the median (range) was 3 (2–10) air pockets. Two patients with multiple air pockets of 10mm-thick cuts or more had small bowel perforation. Six (29%) patients had a single air pocket of less than 10mm and none had bowel perforation. 398 patients had negative CT scan for FIA; two of them were false negative. CT-detected FIA scan had a sensitivity of 50% (95% CI: 6.8%–93.2%), specificity of 95.4% (95% CI: 92.9%–97.2%.), a positive predictive value of 9.5% (95% CI: 1.2%–30.4%) and a negative predictive value of 99.5% (95% CI: 98.2%–99.9%) for detecting bowel perforation. The usefulness index for abdominal CT scan FIA for detecting bowel perforation was 0.23 (not useful). ConclusionsOur study which stemmed from a community-based hospital showed that free intraperitoneal air found on abdominal CT scan of blunt trauma patients was an unreliable radiological finding for bowel perforation. The decision for laparotomy should be based on combined clinical and radiological findings. Conservative management with active observation may avoid unnecessary laparotomy.

A Case of Nonperforative Pyometra with Intraperitoneal Free Air

A Case of Nonperforative Pyometra with Intraperitoneal Free Air

腹腔内遊離ガスを伴った急性気腫性胆嚢炎の1例

腹腔内遊離ガスを伴った急性気腫性胆嚢炎の1例

Emphysematous pyelonephritis: An unusual case of pneumoperitoneum and intra-abdominal wall abscess

Emphysematous pyelonephritis (EPN) is a rare gas-producing life-threatening necrotizing bacterial infection that involves the renal parenchyma and the perirenal tissue. It is encountered primarily in patients with diabetes mellitus or ureteral obstruction associated with perinephric and intrarenal gas. Causative organisms are those normally found in the urinary and gastrointestinal tracts. Multiple gas-producing organisms were the cause of the free intraperitoneal and perinephric air however anaerobic bacteria have been demonstrated in only 1% of cases. We describe a case of EPN, which presented as an acute abdomen with pneumoperitoneum in a diabetic patient. On the exploration, no visceral pathology was found, but the patient had right intra-abdominal wall abscess. Subsequent exploration revealed right pyelonephritis. Thus, presenting an unusual presentation of EPN as pneumoperitoneum and intra-abdominal wall abscess.

Unusual Presentation of a Gangrenous Cholecystitis that Mimics a Bowel Perforation

We report the case of a diabetic 49-year-old man affected by phlegmonous cholecystitis with an unusual radiological presentation mimicking a bowel perforation. Actually, abdomen X-ray showed free intraperitoneal air spots (dark crescent beneath the diaphragm) in the upright positions. We have not found any similar cases in the published literature, except for a case report about an unusual presentation of an emphysematous cholecystitis. The clinical practitioner has to pay attention not to fall into a fixation error during diagnosis.

Pneumoperitoneum Secondary to Emphysematous Cholecystitis: An Unusual Presentation

ABSTRACT We herein report a case of emphysematous cholecystitis (EC) causing pneumoperitoneum with gross ascites, which is a very rare entity. A 64-year-old diabetic man was admitted with diffuse abdominal pain, abdominal distension and fever of 1 week duration. On examination, patient was febrile (38.7oC) and abdominal guarding noted. Laboratory investigations revealed total leukocyte count of 16000/ƒÊl with 90% neutrophils, total bilirubin level of 2 mg/dl (direct 0.60 mg/dl). In erect X-ray abdomen, there was no significant finding. Ultrasonography (USG) abdomen showed cholelithiasis with thickened edematous gallbladder (GB) wall and few reflective echoes in GB fossa. Computed tomography (CT) axial sections revealed the presence of small stones in the gallbladder neck and small amount of intraluminal as well as intramural air. Tiny pockets of free intraperitoneal air was also noted. On intravenous (IV) contrast, there was minimal wall enhancement. Preoperative diagnosis of emphysematous cholecystitis with pneumoperitoneum was made and the same was confirmed in the intraoperative findings. Patient underwent emergency exploratory laparotomy with cholecystectomy and was given required medical management, the postoperative course was uneventful. How to cite this article Singh S, Surendra KL. Pneumoperitoneum Secondary to Emphysematous Cholecystitis: An Unusual Presentation. Panam J Trauma Crit Care Emerg Surg 2014;3(1):39-41.

Prognostic value of abdominal sonography in necrotizing enterocolitis of premature infants born before 33 weeks gestational age

ObjectiveThe purpose of this study was to assess the prognostic value of abdominal sonography in necrotizing enterocolitis (NEC) in preterm infants with a gestational age less than 33weeks of gestation, using surgery and/or death as the primary outcome and stenosis as the secondary outcome. MethodsA retrospective study of 95 premature infants (mean gestational age: 28.6weeks), presenting with NEC between January 2009 and November 2011 and who underwent plain abdominal radiography and sonography, was performed. In uni- and multivariate analyses, radiographic and sonographic findings were correlated with complications (‘surgery and/or death’ and ‘stenosis’). ResultsSonographic findings of free intraperitoneal air (odd ratio [OR]=8.0; IC, 1.4–44.2), free abdominal fluid (OR 3.5; IC 1.3–9.4), portal venous gas (OR 3.9; IC, 1.2–12.9), and bowel wall thickening (OR 2.8; IC,1.1–7.2) were significantly associated with surgery and/or death. Intramural gas was significantly correlated (OR=11.8; IC, 1.5–95.8) with intestinal stenosis following NEC. None of the radiographic findings were associated with complications. ConclusionAbdominal sonography is a reliable tool for the prognostic assessment of NEC in preterm infants.

Tension pneumoperitoneum caused by blunt thoracic trauma

Tension pneumoperitoneum is a rare entity that occurs when free air under pressure accumulates in the abdominal cavity compromising visceral function and blood flow. The case of a 23-year-old man whose chest was run over by the wheels of a truck is presented. He arrived with a severely distended abdomen, significant thoracic trauma, hypoxemia, and elevated airway pressures following intubation. Imaging studies revealed massive intraperitoneal free air. He was treated with a decompressive laparotomy but was not found to have a hollow viscus nor diaphragmatic injury. We hypothesize a possible, as yet unpublished, mechanism: secondary to the patient’s rib fractures and significant torso soft tissue shearing, a defect in the parietal pleura allowed air to track from the thorax inferiorly along subcutaneous and fascial planes, eventually entering into the peritoneal cavity through a violated parietal peritoneum. We present a review of the literature on tension pneumoperitoneum.

Pneumomediastinum and Subcutaneous Emphysema Complicating Colonoscopy

Purpose: Colonoscopy, a widely used procedure for diagnostic and therapeutic purpose, is relatively safe, but not free of complications, among which perforation is common, with 0.4-1.9% incidence. We report a case of colonic perforation presenting with subcutaneous emphysema, pneumomediatinum, and pneumoretroperitoneum complicating therapeutic colonoscopy. Case: A 62-year-old man underwent colonoscopy for evaluation of hematochezia of 1 month's duration. He had multiple colon polyps throughout the colon. Hot snare polypectomy was performed on an isolated right colon polyp, with the rest being removed with a biopsy or cold snare polypectomy. Immediately post procedure, he complained of severe pressure-like chest pain with no associated nausea, dyspnea, diaphoresis, or dizziness. He was noted to develop subcutaneous emphysema involving the neck and left shoulder. Oxygen saturation was 96% on room air. Cell count, comprehensive panel, and cardiac enzymes were normal. EKG showed no evidence of ischemia. Chest x-ray showed sub-diaphragmatic free air. CT scan showed extensive subcutaneous air in the lower part of the neck and mediastinum, along with a large amount of retroperitoneal air dissecting mesentery and around the liver. Free intraperitoneal air was not noted. He was evaluated by surgery service and admitted for observation and conservative management. Due to worsening abdominal pain and tenderness on palpation, he underwent emergent exploratory laparotomy, which did not reveal any evidence of bowel perforation. A colonic perforation was suspected, but not identified. It was postulated that a microperforation had closed spontaneously after decompression of the bowel. The patient continued to do well, and recovered from surgery. Discussion: Incidence of colon perforation is common with therapeutic, as compared to diagnostic, colonoscopy. Subdiaphragmatic free air suggest intraperitoneal perforation, whereas subcutaneous emphysema, pneumoretroperitoneum, and pneumomediatinum suggest extraperitoneal perforation. Extraperitoneal perforation without peritoneal signs can be treated conservatively with bowel rest and antibiotics. Microperforation usually close with omental adherence, and symptoms resolve within 24-48 hours.Figure: CT Chest showing pneumomediastinum.

Primary Colorectal Non-Hodgkinʼs Lymphoma in the Setting of Ulcerative Colitis: A Rare Occurrence with an Unusual Presentation

Introduction: The GI tract is a common site for primary lymphoma (10-15%), and also as an extranodal site (30-40%). Colorectal involvement, however, is rare, accounting for 3% of GI lymphoma and only 0.3 % of colonic malignancies. The concomitant presence of ulcerative colitis and DLBCL is exceedingly rare, and diagnosis is often delayed, owing to overlap of symptoms. Case: A 71-year-old man with a history of ulcerative colitis (UC) and coronary artery disease was admitted with abdominal pain, persistent diarrhea and weight loss. He had an antecedent history of colitis for at least 8 years, with biopsies consistent with infectious colitis vs. early inflammatory bowel disease, treated with mesalamine and, intermittently, with antibiotics during exacerbations; he was never treated with immune modulators. Prior imaging, including CT scans, had revealed mild colonic mural thickening with a “featureless” transverse colon, suggestive of ulcerative colitis, but no radiographic evidence of malignancy. While undergoing bowel prep for colonoscopy, he complained of sudden worsening of abdominal pain. A CT scan revealed a large volume of intraperitoneal free air, consistent with a bowel perforation and an inflammatory state of the sigmoid and descending colon, compatible with ulcerative colitis. An emergent resection and colostomy was performed. The histopathology was consistent with a diffuse large B cell lymphoma (DLBCL) with adjacent segments of colon showing chronic colitis and focal ulceration, negative for transmural inflammation, consistent with the diagnosis of ulcerative colitis. He was subsequently treated with six cycles of rituxan and EPOCH, and is currently in remission and followed by oncology. Repeat PET/CT imaging to date has not shown any recurrence of disease. Discussion: We present this case of DLBCL in a patient with UC who presented with vague abdominal symptoms and was not on immunosuppressive medications. The link between UC and colonic lymphoma remains unresolved. Hypotheses include ongoing treatment with immunosuppressive agents vs. chronic inflammation in the setting of UC as the inciting factor for development of lymphoma. Further study is needed to define the relationship between UC and primary colonic lymphoma. Colonic lymphoma tends to present with vague abdominal and systemic symptoms often overlapping with those characteristic of inflammatory bowel disease. This, along with the potential for colonic lymphomas to present as ulcerative lesions, makes it difficult to distinguish from UC. Perforations are exceedingly rare. Given the unusual occurrence of primary colonic lymphoma in the setting of UC and the overlap of symptoms, a high index of suspicion is needed.

Transient serosal enhancement mimicking pneumoperitoneum

Sir, In a prior issue of this journal, we reported two cases of a novel enhancement pattern involving the pericardium, peritoneum and soft tissues seen on radiographs in the early post-cardiac catheterization period [1]. Knowledge of this phenomenon is clinically important because the enhancement pattern renders a relative lucency over the liver. We report a third case of this radiographic phenomenon that mimicked the appearance of pneumoperitoneum and led to an exploratory laparotomy. A baby girl with hypoplastic left heart variant including a double-outlet right ventricle and restrictive atrial septum was born by cesarean section at 37 2/7 weeks to a gravida I para I woman. Cardiac catheterization was performed on the day the child was born for stent placement into veins decompressing into the left atrium. At 5 days old, the newborn was taken for a Norwood/Sano procedure and atrial septectomy. A complicated post-operative course followed, including renal insufficiency, respiratory failure, poor cardiac function, acidosis and delayed sternotomy closure. The infant was taken back to the cardiac catheterization lab to evaluate the pulmonary veins. A radiograph of the chest and abdomen obtained within 24 h of completion of the cardiac catheterization suggested the presence of free intraperitoneal air, characterized by a conspicuous relative lucency over the right upper quadrant (Fig. 1). A left lateral decubitus view did not confirm the presence of pneumoperitoneum. However, given the suggestive findings of pneumoperitoneum on the supine radiograph and the infant’s clinical condition, the child was taken to the operating room. Findings during the exploratory laparotomy were negative. The classic findings of pneumoperitoneum on supine abdominal radiography include radiolucency over the liver [2].

CT scan-detected pneumoperitoneum: An unreliable predictor of intra-abdominal injury in blunt trauma

IntroductionFree intra-peritoneal air in blunt trauma is a classic sign associated with hollow viscus injury, traditionally mandating laparotomy. In blunt abdominal trauma, the CT scan has become the diagnostic modality of choice. The increased sensitivity of CT scans may lead to detection of free intra-peritoneal air that is not clinically significant. ObjectiveTo characterize conditions and findings that allow for the safe observation of blunt trauma patients with free air and to propose a patient management algorithm to decrease rates of non-therapeutic laparotomy. DesignA retrospective review of 5877 blunt trauma patients who had an abdominal CT scan upon admission to our hospital from 2003 to 2011. A secondary CT review was performed by a single radiologist to further characterize the CT findings in the 74 patients with free air reported on initial scan. Management and hospital course were reviewed in these patients. ResultsOf the 74 patients with intra-abdominal free air, 36 patients with a benign clinical picture were observed and 38 patients underwent urgent exploratory laparotomy. Eleven patients received a non-therapeutic laparotomy. The majority (61%) of patients, 45 of 74, had free air and no significant injury suggesting the presence of benign free air. Patients who had intra-abdominal injury also typically had other clinical or radiologic signs of injury. Findings that were highly predictive of intra-abdominal injury in the setting of free air were free fluid (P<0.001), radiographic signs of bowel trauma (P<0.001) as well as clinical and/or radiographic seatbelt sign (P=0.004). ConclusionsCT scans may detect free air that is not always clinically significant. Free fluid, seatbelt sign or radiographic signs of bowel trauma in the presence of pneumoperitoneum is highly predictive of injury and these patients should be explored. Based on the results of our study, we created an algorithm to aid in identifying those patients with intra-abdominal free air who may be observed safely.

Perforations following endoscopic retrograde cholangiopancreatography: a single institution experience and surgical recommendations

BackgroundPerforation after endoscopic retrograde cholangiopancreatography (ERCP) is uncommon, and its management is dependent on the mechanism and the graded classification of injury. MethodsRecords of patients undergoing ERCP were analyzed over a 16-year period, patterning the types of injuries, diagnosis, management, and patient outcome. Type I injuries damage the medial or lateral duodenal wall before sphincter cannulation. Type II injuries are periampullary and occur as a result of a precut or a papillotomy. Type III injuries occur secondary to guidewire insertion or stone extraction from the common bile duct. Type IV injuries are probably microperforations that are noted on excessive insufflation during and after ERCP withdrawal. ResultsBetween 1995 and 2011, 27 perforations were identified from 1,638 ERCP procedures (1.6%). Nearly half of the procedures were regarded as difficult by the endoscopist, with 70% of the ERCPs (19 of 27) being for therapeutic indications. There were 5 type I, 12 type II, 5 type III, and 5 type IV perforations, of which 18 cases were diagnosed at the time of ERCP. Delayed diagnosis of type I perforations that were associated with free intraperitoneal air and contrast leakage proved fatal. Most type II perforations required immediate surgery with pyloric exclusion; delayed surgery with simple drainage had a high mortality rate. Most type III and type IV injuries can successfully be managed conservatively without delayed sepsis. ConclusionsIn perforation, the mechanism of injury during ERCP predicts the need for surgical management. Type I and type II injuries require early diagnosis and aggressive surgery, whereas type III and type IV injuries may be managed conservatively.

Gastrointestinal perforation: ultrasonographic diagnosis

Gastrointestinal tract perforations can occur for various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body or a neoplasm that require an early recognition and, often, a surgical treatment.Ultrasonography could be useful as an initial diagnostic test to determine, in various cases the presence and, sometimes, the cause of the pneumoperitoneum.The main sonographic sign of perforation is free intraperitoneal air, resulting in an increased echogenicity of a peritoneal stripe associated with multiple reflection artifacts and characteristic comet-tail appearance.It is best detected using linear probes in the right upper quadrant between the anterior abdominal wall, in the prehepatic space.Direct sign of perforation may be detectable, particularly if they are associated with other sonographic abnormalities, called indirect signs, like thickened bowel loop and air bubbles in ascitic fluid or in a localized fluid collection, bowel or gallbladder thickened wall associated with decreased bowel motility or ileus.Neverthless, this exam has its own pitfalls. It is strongly operator-dependant; some machines have low-quality images that may not able to detect intraperitoneal free air; furthermore, some patients may be less cooperative to allow for scanning of different regions; sonography is also difficult in obese patients and with those having subcutaneous emphysema. Although CT has more accuracy in the detection of the site of perforation, ultrasound may be particularly useful also in patient groups where radiation burden should be limited notably children and pregnant women.

The conservative management of pneumoperitoneum in children

Objective Pneumoperitoneum is usually the result of hollow visceral perforation and requires emergent laparotomy.However,about 10％ of patients lack a pathologic cause requiring surgical intervention and can be resolved with conservative management.The aim of this study is to discuss the indications for conservative management of pneumoperitoneum in children.Methods We retrospectively reviewed the data of 5 children with pneumoperitoneum without peritonitis treated in our pediatric surgery department between January 2009 and December 2010.Results There were 5 children with an average age 5.4 years.Radiologic examinations demonstrated pneumoperitoneum and visceral perforations were suspected in the local hospitals.The abdominal examination revealed no peritoneal signs in all patients.Among them,peritoneal aspirations were implemented in 4 patients and the results were negative.One of five patients underwent laparotomy that demonstrated no visceral perforation.The remaining four were successfully managed conservatively and the pneumoperitoneum was completely resolved between 3 and 9 days.All children were without abdominal symptoms and signs throughout at least 2 years follow-up.Conclusion The presence of free intraperitoneal air does not always indicate hollow visceral perforation and the need for emergent laparotomy.It appears that therapeutic effectiveness can be readily achieved with conservative management in children with pneumoperitoneum without peritonitis. Key words: Pneumoperitoneum; Conservative management; Peritonitis; Children

Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air

Department of Surgery University of Nebraska Medical Center Omaha, Nebraska The author declares no conflicts of interest.

Re: Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air

Re: Mandatory exploration is not necessary for patients with acute diverticulitis and free intraperitoneal air