Purpose: Describe a case of Spontaneous Idiopathic Pneumoperitoneum and examine the surgery-sparing algorithm used for diagnosis. Case Report: A 57-year-old male with a history of lymphocytic colitis presented with complaints of nausea and scapular pain for 2 days. A CT scan revealed intraperitoneal air. The patient had no leukocytosis or fever. Based on his physical exam, however, he underwent an exploratory laparotomy. The surgery was nondiagnostic and unrevealing. After an uneventful hospital stay, the patient was discharged. Outpatient follow-up imaging showed resolution of the pneumoperitoneum. Five months after his initial presentation, the patient again presented with similar complaints. Again, he had a considerable amount of free air on CT scan. The patient preferred to avoid a laparotomy at this time. As he remained hemodynamically stable, he was treated with IV antibiotics and bowel rest. Extensive radiographic and gastrointestinal investigation was pursued instead of repeating surgery. An upper GI series with small bowel follow through was negative for extra luminal contrast. Subsequent barium enema also failed to show any contrast leak. The patient then completed a capsule endoscopy. However the study was normal and no pathology which could be targeted by double balloon enteroscopy was found. As the patient's symptoms continued to improve with conservative management, he was diagnosed with recurrent Spontaneous Idiopathic Pneumoperitoneum and a repeat laparotomy was avoided. At a one-year follow up, the patient remained clinically asymptomatic. Discussion: First described as a radiographic entity in 1915, spontaneous pneumoperitoneum has remained a rare condition. Historically, the most common causes have been PUD, diverticular rupture, and abdominal trauma. However, of all the cases of spontaneous pneumoperitoneum, 10% are considered to be idiopathic and by definition an etiology is not identified. Pneumoperitoneum in these cases results from benign sources. Most importantly, these patients do not require surgery and can be treated conservatively. In our patient, the diagnostic investigations, which included initial radiographic studies (Upper GI Series, SBFT, BE) followed by capsule endoscopy, allowed us to confirm a diagnosis of Spontaneous Idiopathic Pneumoperitoneum. As no pathology which required emergent surgery was found and our patient remained hemodynamcially stable, we were able to successfully avoid a non-diagnostic surgical procedure. Consequently, if these cases can be properly and systematically identified with a diagnostic algorithm similar to the one we employed, costly and not-without-risk surgical interventions can be avoided without any compromise to patient safety.