Treatment of Pneumoperitoneum
Patients with pneumoperitoneum and signs of peritonitis require immediate surgical intervention, as every hour of delay decreases survival probability by 2.4%. 1
Initial Assessment and Risk Stratification
The management of pneumoperitoneum depends critically on clinical presentation rather than imaging findings alone:
Assess for peritonitis signs: Patients with diffuse peritonitis, hemodynamic instability, or systemic inflammatory response require immediate surgical exploration without delay for additional imaging. 1, 2
Obtain contrast-enhanced CT scan in hemodynamically stable patients without overt peritonitis to determine the cause, site of perforation, and identify complications such as abscess formation. 2
Do not delay surgery for imaging if there are clear signs of diffuse peritonitis or hemodynamic instability—proceed directly to the operating room. 2
Surgical Management Algorithm
For Unstable Patients or Diffuse Peritonitis
Immediate laparotomy is mandatory for patients with hemodynamic instability, diffuse peritonitis, or progressive clinical deterioration. 1
Damage control surgery may be appropriate for critically unstable patients. 1
Primary surgical objectives include: determining the cause of peritonitis, controlling the source of contamination through resection or suture of perforated viscus, removing infected organs, debriding necrotic tissue, and draining fluid collections. 1
For Stable Patients with Confirmed Perforation
Laparoscopic approach is preferred for hemodynamically stable patients with perforated peptic ulcer, as it allows adequate diagnosis and treatment with less invasive access. 1
Open approach should be used for hemodynamically unstable patients, when laparoscopic expertise/equipment is unavailable, or in critically ill patients where pneumoperitoneum may worsen cardiovascular and pulmonary physiology. 1
Specific Surgical Procedures by Etiology
For perforated peptic ulcer: Laparoscopic repair is preferred in stable patients; open approach for unstable patients. 1
For diverticular disease with diffuse peritonitis: Hartmann's procedure is recommended for critically ill patients and those with multiple comorbidities. 1
For colonic obstruction or perforation: Hartmann's procedure is preferred over simple colostomy to avoid longer hospital stay and multiple operations. 1
Conservative (Non-Operative) Management
Conservative management is appropriate only in highly selected cases:
Sealed perforated peptic ulcer confirmed on water-soluble contrast study may be managed non-operatively. 1
Diverticulitis with small amounts of pericolic air without diffuse peritonitis or fluid in Douglas pouch may respond to antibiotics alone. 1
Appendiceal abscess or phlegmon can be treated conservatively with antibiotics, with or without percutaneous drainage, resulting in fewer complications than immediate appendectomy. 1
Well-localized fluid collections without extensive loculations can be drained percutaneously. 1
Criteria for Conservative Management
Conservative treatment requires ALL of the following 1, 2:
- Hemodynamic stability
- Absence of diffuse peritonitis
- Minimal free air on imaging
- Clinical response to initial therapy
- Close observation capability
Predictors of Conservative Management Failure
Large amounts of distant intraperitoneal or retroperitoneal air are associated with 57-60% failure rate with conservative management. 1
Diffuse intra-abdominal fluid is a key imaging finding predicting surgical need. 1
Common Pitfalls to Avoid
Do not underestimate the time-mortality relationship: Every hour of surgical delay increases mortality by 2.4%, making timely intervention critical. 1
Do not rely solely on imaging: Approximately 10% of pneumoperitoneum cases are non-surgical (postoperative retained air, thoracic causes, gynecologic causes, idiopathic), but clinical examination determines management. 3
Do not attempt complex resections in hemodynamically unstable patients—damage control surgery is more appropriate. 1
Do not delay surgery to obtain additional imaging in patients with clear peritonitis signs, as this increases mortality risk. 2
Recognize that plain X-rays have low sensitivity for detecting pneumoperitoneum, and repeated radiographs after intervention can be deleterious if falsely negative. 4