From the Guidelines
Pneumoperitoneum is primarily caused by perforation of a hollow viscus organ, most commonly the gastrointestinal tract, and the most frequent causes include perforated peptic ulcers, perforated appendicitis, diverticulitis, and traumatic bowel injuries 1. The causes of pneumoperitoneum can be categorized into several main groups, including:
- Iatrogenic causes, such as after laparoscopic surgery where carbon dioxide gas is intentionally introduced into the peritoneal cavity
- Perforation of a hollow viscus organ, such as the gastrointestinal tract
- Less common causes, including perforated gallbladder, gynecological conditions like pelvic inflammatory disease, and barotrauma from mechanical ventilation
- Rare cases of pneumoperitoneum without perforation, due to pneumomediastinum, pneumothorax, or peritoneal dialysis 1 The site of perforation is also an important factor in determining the cause of pneumoperitoneum, and imaging studies such as CT scans can help identify the site and size of the perforation 1. In terms of diagnosis, the clinical presentation of pneumoperitoneum can vary, but common symptoms include acute abdominal pain, distension, and rigidity 1. The presence of free air in the peritoneal cavity is a key diagnostic finding, and can be detected using imaging studies such as plain X-ray, CT scan, or ultrasound 1. The management of pneumoperitoneum depends on the underlying cause and severity of the condition, and may include conservative management, endoscopic treatment, or surgical intervention 1. In general, pneumoperitoneum from perforation requires urgent medical attention, often including antibiotics, fluid resuscitation, and surgical intervention to repair the perforation and clean the peritoneal cavity 1.
From the Research
Causes of Pneumoperitoneum
- Pneumoperitoneum can be caused by various factors, including perforation of the gastrointestinal tract 2, 3, 4
- Non-surgical causes of pneumoperitoneum include postoperatively retained air, thoracic, abdominal, gynecologic, and idiopathic factors 2
- Pneumoperitoneum can also result from pneumomediastinum and pneumothorax, and in patients who are being mechanically ventilated 5
- Traumatic blunt injuries can also lead to pneumoperitoneum, with the jejunum and ileum being the most common sites of perforation 3, 4
Clinical Presentation and Diagnosis
- Signs of peritoneal sepsis are the most consistent findings in patients with pneumoperitoneum 4
- Radiological evidence of perforation, such as pneumoperitoneum, can be present on plain abdominal radiographs or computed tomographic scans 3, 4, 5
- Patient history and physical examination can assist in a preliminary diagnosis before diagnostic imaging 5
Management and Treatment
- Surgical versus nonsurgical conservative observation is determined on the basis of the cause and amount of free air 5
- Operative intervention is associated with reduced mortality in patients with pneumoperitoneum and peritonitis 6
- Nonoperative treatment is warranted in the absence of symptoms and signs of peritonitis 2, 6