Gerta Repečkaitė1, Tomas Jurevičius1, Jurgita Zaveckienė1
1Department of Radiology of Lithuanian University of Health Sciences Kaunas, Lithuania.
Background: Typically, the presence of air or fluid in the thoracic and abdominal cavities is considered to be of separate origin. However, it is essential to take into consideration that a non-surgical pneumoperitoneum (NSP) may develop without a perforated viscus, and due to thoracic causes, such as mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. This is important in clinical practice, because exclusion of intestinal perforation alters patient management, and prevents unnecessary surgical interventions.
Aim: This article aims to review the causes and imaging findings of an NSP and present a patient with unilateral tension pneumothorax, pneumomediastinum, pneumoretroperitoneum, subcutaneous emphysema, and pneumoperitoneum, which were not associated with a perforated viscus.
Case report: A 65-year-old male was admitted to the Emergency Department (ED) due to seizures and impaired consciousness. Prior to arrival, the ambulance personnel had intubated the patient. A chest x-ray and chest-abdomen-pelvis CT scan showed a massive left pneumothorax with mediastinal shift to the right, lung collapse, and pronounced bilateral subcutaneous emphysema, a small pleural effusion on the right, an eighth rib fracture on the left, pneumomediastinum, ectopic air in the abdominal cavity, between the muscle/fascia layers, and in the retroperitoneum. A laparotomy and esophagogastroduodenoscopy excluded duodenal and other intestinal perforation. The patient was treated conservatively, and within fifteen days, was discharged home.
Conclusion: In conclusion, attention, critical thinking, and knowledge of atypical causes are crucial when evaluating a patient with pneumoperitoneum, as it may develop without the perforation of a hollow viscus, and may not require surgical treatment.