What is the treatment for pneumoperitoneum?

Management of Pneumoperitoneum

Patients with pneumoperitoneum who present with signs of peritonitis, hemodynamic instability, or evidence of perforation on imaging require immediate surgical exploration. 1

Diagnostic Approach

• Imaging studies are essential for diagnosis:
  • Plain abdominal radiographs can detect free peritoneal air with 92% positive predictive value
  • Contrast-enhanced CT scan is preferred for detecting small amounts of free air and identifying the source of perforation 1
  • Do not delay surgical intervention for imaging in hemodynamically unstable patients

Treatment Algorithm

Surgical Management (First-Line)

Immediate surgical intervention is indicated for:

• Pneumoperitoneum with signs of peritonitis
• Extraluminal contrast extravasation on imaging
• Hemodynamic instability
• Suspected bowel perforation 1

Surgical options depend on the cause and patient condition:

• For patients with pneumoperitoneum due to diverticulitis with peritonitis:

  • Hartmann's procedure for critically ill patients or those with multiple comorbidities
  • Primary resection with anastomosis (with/without diverting stoma) for clinically stable patients with no major comorbidities 2

• For patients with colon obstruction or perforation:

  • Left colonic obstruction: loop colostomy (shorter operative time) or Hartmann's procedure
  • Hartmann's procedure is preferred over simple colostomy to avoid longer hospital stay and multiple operations 2

• Surgical approach:

  • Open approach for hemodynamically unstable patients
  • Laparoscopic approach may be considered in stable patients if expertise exists 1

Important: Each hour of delay beyond hospital admission is associated with a 2.4% decreased probability of survival compared to the previous hour 1

Non-Operative Management (Selected Cases)

Non-operative management may be considered in:

• Patients with sealed perforations confirmed by water-soluble contrast studies
• Asymptomatic pneumoperitoneum without signs of peritonitis or sepsis 1
• Certain post-procedural pneumoperitoneum (e.g., after PEG tube placement) 1

A recent study found that in patients without peritonitis, non-operative treatment was associated with:

• Similar mortality outcomes compared to surgical intervention
• Lower rates of dependence on enteral tube feeding or TPN
• Higher rates of home discharge 3

Special Considerations

1. Elderly patients (>70 years) have higher mortality if non-operative management fails, warranting a lower threshold for surgical intervention 1

2. Post-procedural pneumoperitoneum:

   • Radiological evidence of pneumoperitoneum is frequently observed after PEG tube placement (>50% of cases) and may not require intervention 1
   • Pneumoperitoneum after colonoscopy may indicate iatrogenic perforation requiring urgent intervention 1

3. Non-surgical causes account for approximately 10% of pneumoperitoneum cases and include:

   • Post-operative retained air
   • Thoracic causes (mechanical ventilation, CPR)
   • Gynecologic causes 4

4. Clinical peritonitis is the key decision point:

   • In patients with clinical peritonitis, operative treatment is associated with significantly reduced mortality (OR 0.17,95% CI, 0.04-0.80) 3
   • In the absence of peritonitis, operative treatment may increase morbidity and reduce chances of home discharge 3

Pitfalls to Avoid

• Unnecessary laparotomy in patients with non-surgical pneumoperitoneum (approximately 10% of cases) 4
• Delaying surgery in patients with peritonitis (each hour delay reduces survival probability) 1
• Failing to recognize post-CPR pneumoperitoneum, which may not always require surgical intervention 5
• Overlooking pneumoperitoneum as a complication of mechanical ventilation 6