From the Guidelines
Pneumoperitoneum can occur without surgery or abdominal trauma, and common nonsurgical causes include gastrointestinal perforation, iatrogenic causes, gynecological causes, and pulmonary conditions. The management of pneumoperitoneum depends on the underlying cause and the patient's clinical status, with asymptomatic patients potentially only requiring observation, while those with signs of peritonitis need urgent surgical evaluation 1. Some of the nonsurgical causes of pneumoperitoneum include:
- Gastrointestinal perforation from peptic ulcer disease, diverticulitis, or inflammatory bowel disease
- Iatrogenic causes, such as endoscopic procedures like colonoscopy or ERCP, peritoneal dialysis catheter placement, and post-procedural air insufflation 1
- Gynecological causes, including vaginal procedures, sexual activity, douching, and pelvic inflammatory disease
- Pulmonary conditions like mechanical ventilation, COPD, and asthma, which can cause pneumoperitoneum through alveolar rupture and air dissection along bronchovascular sheaths
- Rare causes, such as pneumatosis intestinalis, emphysematous cholecystitis, and spontaneous bacterial peritonitis The diagnostic workup for pneumoperitoneum typically includes abdominal imaging, such as X-ray or CT scan, and laboratory tests to determine the underlying cause 1. In cases where the pneumoperitoneum is discovered incidentally without symptoms, it is termed "benign pneumoperitoneum" and may not require immediate intervention. However, patients with signs of peritonitis, such as abdominal pain, fever, and tenderness, require urgent surgical evaluation and potential intervention to prevent further complications 1.
From the Research
Nonsurgical Causes of Pneumoperitoneum
- Nonsurgical pneumoperitoneum can be caused by various factors, including postoperative retained air, thoracic, abdominal, gynecologic, and idiopathic sources 2, 3, 4
- The most common abdominal etiology of nonsurgical pneumoperitoneum is retained postoperative air, with a prevalence of 25% to 60% 4
- Thoracic causes of nonsurgical pneumoperitoneum include mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax 4
- Gynecologic causes of nonsurgical pneumoperitoneum can also occur, although they are less common 2, 3
- Idiopathic causes of nonsurgical pneumoperitoneum have also been reported, where no clear source of the pneumoperitoneum can be identified 2, 3
Clinical Presentation and Management
- Nonsurgical pneumoperitoneum can present with a range of symptoms, from asymptomatic to severe abdominal pain and distension 3, 5
- The management of nonsurgical pneumoperitoneum depends on the underlying cause and the presence of symptoms or signs of peritonitis 2, 4
- Conservative management with observation and supportive care may be indicated in many cases of nonsurgical pneumoperitoneum, especially in the absence of symptoms or signs of peritonitis 2, 4
- However, a low threshold for intervention should be maintained, especially in cases with confounding findings or uncertain diagnosis 6
Specific Causes and Associations
- Blunt chest trauma can cause nonsurgical pneumoperitoneum by leaking air through microscopic diaphragmatic defects or the mediastinum along perivascular connective tissue 5
- Endoscopy-induced barotrauma and benign pneumoperitoneum can occur as concomitant complications, requiring careful management and consideration of intervention 6
- Peritoneal dialysis catheter placement and gastrointestinal endoscopic procedures can also cause nonsurgical pneumoperitoneum, with varying prevalence rates 4