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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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Table of Contents   
LETTERS TO THE EDITOR
Year : 2018  |  Volume : 23  |  Issue : 4  |  Page : 240-241
 

Pneumoperitoneum: Not always due to an intestinal perforation!!


Department of Pediatric Surgery, VMMC and Safdarjung Hospital, New Delhi, India

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Nidhi Sugandhi
Department of Pediatric Surgery, VMMC and Safdarjung Hospital, Ward 19, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_248_17

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How to cite this article:
Sugandhi N, Samraj P, Acharya SK, Jadhav A, Tekchandani N, Bagga D. Pneumoperitoneum: Not always due to an intestinal perforation!!. J Indian Assoc Pediatr Surg 2018;23:240-1

How to cite this URL:
Sugandhi N, Samraj P, Acharya SK, Jadhav A, Tekchandani N, Bagga D. Pneumoperitoneum: Not always due to an intestinal perforation!!. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2018 Dec 10];23:240-1. Available from: http://www.jiaps.com/text.asp?2018/23/4/240/242714




Sir,

Pneumoperitoneum or presence of free air in the abdominal cavity is most commonly due to perforation of a hollow viscus. An abdominal radiograph showing pneumoperitoneum along with clinical signs of peritonitis necessitates emergency abdominal exploration. We came across a case where a child presented with peritonitis and free abdominal air but on exploration was found to have empyema secondarily causing pneumoperitoneum.

A 4-year-old male child presented to the emergency with severe right upper quadrant abdominal pain, distension, and vomiting for 2 days. He also had a history of high-grade fever and cough for the past 20 days. On examination, the child was febrile and had tachycardia and severe tenderness and guarding in the right side of the abdomen. An erect abdominal X-ray revealed pneumoperitoneum with severe right-sided pneumonitis [Figure 1]. On laparoscopic exploration, there was a large loculated suprahepatic pus collection, but rest of the abdominal viscera including the liver was normal [Figure 1]. Further exploration after clearing the pus revealed a right-sided diaphragmatic rent with irregular margins measuring approximately 1 cm diameter through which pus was passing from the right thoracic cavity into the abdomen. The diaphragmatic defect was small, central and had jagged edges, thus ruling out congenital diaphragmatic hernia. Thus, the diagnosis of right-sided empyema secondarily causing diaphragmatic rupture and pyopneumoperitoneum was confirmed. Thorough lavage of the pyoperitoneum and right-sided intercostal drain (ICD) insertion was done. The child recovered with high-grade antibiotics and chest physiotherapy. ICD was removed after 4 days once the output stopped and pneumonitis resolved. A check postoperative ultrasound was also done to rule out liver abscess, which was normal.
Figure 1: X-ray showing pneumoperitoneum and laparoscopic image showing normal liver (white arrow) with diaphragmatic rent (black arrow) and pus trickling from right thoracic cavity into the abdomen

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Less than 5% cases of pneumoperitoneum in children are due to causes other than hollow viscus perforation.[1] The most common nonsurgical causes of pneumoperitoneum in children are cardiopulmonary resuscitation, mechanical ventilation, gynecologic manipulation, peritoneal dialysis, and gastrointestinal endoscopic procedures.[2],[3] These cases can be suspected preoperatively due to predisposing conditions such as mechanical ventilation and absence of peritonitis. Our patient had peritonitis, systemic signs, and no predispositions, thus obviating any suspicion of nonsurgical pneumoperitoneum. Nevertheless, this case highlights that in a patient with clinical and radiological evidence of peritonitis but with negative laparotomy findings, thorough search for alternative pathologies, which may not necessarily be abdominal, needs to be undertaken.

Although empyema can cause complications such as loculation, lung collapse, and cutaneous fistulas, empyema causing diaphragmatic rupture and secondary abdominal peritonitis is not known. Such cases provide interesting exceptions to established surgical beliefs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mularski RA, Sippel JM, Osborne ML. Pneumoperitoneum: A review of nonsurgical causes. Crit Care Med 2000;28:2638-44.  Back to cited text no. 1
    
2.
Karaman A, Demirbilek S, Akin M, Gürünlüoğlu K, Irşi C. Does pneumoperitoneum always require laparotomy? Report of six cases and review of the literature. Pediatr Surg Int 2005;21:819-24.  Back to cited text no. 2
    
3.
Gummalla P, Mundakel G, Agaronov M, Lee H. Pneumoperitoneum without intestinal perforation in a neonate: Case report and literature review. Case Rep Pediatr 2017;2017:6907329.  Back to cited text no. 3
    


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