Case Series
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Conservative management for spontaneous pneumoperitoneum | ||||||
Michael Morrison1, Sarah Brown1, Ryan Enders1, Ranjeet Kalsi1, Christopher Esper1 | ||||||
1UPMC Horizon, 2200 Memorial Dr Farrell, PA, USA
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Morrison M, Brown S, Enders R, Kalsi R, Esper C. Conservative management for spontaneous pneumoperitoneum. Edorium J Surg 2018;5:100028S05MM2018. |
ABSTRACT
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Introduction: To improve and standardize care of patients who present with spontaneous pneumoperitoneum in order to decrease morbidity and mortality due to non-therapeutic laparotomy or laparoscopy. Case Series: A retrospective case series was conducted at University of Pittsburgh Medical Center (UPMC) Horizon from April 2011 to September 2016. Hospital EHR was searched to identify patient records containing ICD-9/10 codes for pneumoperitoneum. All charts were then examined and any cases with an identifiable etiology for the pneumoperitoneum (perforated peptic ulcer disease or perforated diverticulitis) were excluded. A total of five cases of spontaneous pneumoperitoneum were identified at UPMC Horizon during the allotted time period. Mean age at 55.4 with four male and one female patient. Four patients were managed non-operatively with empiric antibiotics, bowel rest and serial abdominal exams. One patient was taken to the operating room for non-therapeutic laparotomy. All five patients were discharged from the hospital in stable condition. Conclusion: Perforated viscous requiring emergent surgical intervention is the most common cause of pneumoperitoneum. There are numerous other causes of pneumoperitoneum that must always be kept in the differential diagnosis. Patients with pneumoperitoneum who demonstrate hemodynamic instability, peritonitis, leukocytosis, identifiable hollow viscous source on cross sectional imaging or meet SIRS criteria should urgently undergo exploration. Patients that do not meet these criteria may be safely observed. Our case series demonstrates that some of these patients may safely be treated non-operatively and be spared the morbidity and mortality of exploration. Keywords: Non-operative, Pneumoperitoneum, Pneumatosis | ||||||
INTRODUCTION
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Spontaneous pneumoperitoneum presents a therapeutic dilemma for the general surgeon. Pneumoperitoneum is defined a free intraperitoneal air which is outside the gastrointestinal tract. Spontaneous pneumoperitoneum refers to the presence of free intraperitoneal airwithout an identified attributing event or pathology. Although the majority of patients who present with free air in the abdomen require emergent surgical intervention due to a perforated viscous, in up to 10 percent of cases, the extra peritoneal air is from another source [1] and non-operative management can be safely attempted in carefully selected patients. The general surgery department at UPMC Horizon encountered five patients over the last five years who presented with pneumoperitoneum without clinically apparent etiology. | ||||||
CASE SERIES
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A retrospective case series was conducted at UPMC Horizon from April 2011 to September 2016. Hospital EHR was searched to identify patient records containing ICD-9/10 codes for pneumoperitoneum. All charts were then examined and any cases with an identifiable etiology for the pneumoperitoneum (perforated peptic ulcer disease or perforated diverticulitis) were excluded. Any patients who presented with peritonitis, hemodynamic instability, acidosis or evidence of systemic inflammatory response were also excluded. A total of 31 cases of pneumoperitoneum were discovered, however 26 were excluded, so five patients were identified that met the inclusion criteria over the five year period examined. Imaging from these cases is not available in our PACs system.
Case 1
Case 2
Case 3
Case 4
Case 5 | ||||||
DISCUSSION | ||||||
The finding of free air on imaging indicates urgent surgical evaluation with the most common cause related to a perforated hollow viscous.Such an injury requires urgent intervention to prevent sepsis and mortality. However, a nonsurgical source is responsible in approximately 10 percent of cases [2]. There are numerous causes of pneumoperitoneum (see Table 1) and these need to be kept in the differential diagnosis during patient evaluation, because many of these causes do not require surgical repair. This case series represents five patients who had radiographic evidence pneumoperitoneum without evidence of hollow viscous perforation. Four patients were treated non-operatively and one underwent a non-therapeutic laparotomy. All patients were discharged from the hospital in stable condition once discharge criteria were met. Pneumatosis intestinalis was identified as the potential source of the free air in two of the five cases. This disease process has a broad differential diagnosis including bowel obstruction, ischemia/necrosis, IBD, neoplasms, enteritis, appendicitis, tuberculosis, adhesions, a prior end to end anastomosis, obstructive pulmonary disease, drug-induced, pyloric stenosis, immunosuppression related, trauma, or it may be idiopathic [3], [4], [5]. The presentations of patients with pneumatosis intestinalis range from asymptomatic to septic shock. Patients may require surgical intervention or simply observation depending on clinical findings and ultimately the cause of the pneumatosis. It has been suggested that the use of high flow oxygen therapy may be of some utility in improving the resolution of the pneumotosis [6]. This therapy is not without its own risks. Researchers first took note of the damaging effects of oxygen as early as the late nineteenth century. The mechanism of oxygen toxicity is attributed to oxygen-free radicals. These reactive oxygen species have one or more free electrons, making them unstable. These molecules may combine with other species and cause cellular damage. These may directly or indirectly react with lipids, DNA, and proteins, causing cell signaling abnormalities to significant damage in the form of necrosis and apoptosis. Neither of the two cases identified to have pneumatosis in this case series were treated with high flow oxygen therapy [7]. This raises the question, though there may be a theoretical benefit of high flow oxygen, does it have any clinical benefit or reduce morbidity and mortality. The other three cases in the series had no identified etiology for their pneumoperitoneum. All of these patients were successfully managed non-operatively and discharged from the hospital without adverse event. An interesting pattern that was revealed in this series is that all of these patients were treated with parenteral antibiotics, even though these patients had no evidence of infection. It is doubtful that the addition of antibiotics contributed to the positive outcome in these cases and only contributed antibiotic resistance. This observation will require additional study. There are several limitations to case series. The first being that this represents a small sample size only including five patients. This is due to the uncommon nature of this disease process. Another limitation is that this series is retrospective in nature. A prospective follow-up study would be ideal to test these recommendations. | ||||||
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CONCLUSION | ||||||
Perforated viscous requiring emergent surgical intervention is the most common cause of pneumoperitoneum. There are numerous other causes of pneumoperitoneum that must always be kept in the differential diagnosis. Patients with pneumoperitoneum who demonstrate hemodynamic instability, peritonitis, leukocytosis, identifiable hollow viscous source on cross sectional imaging or meet SIRS criteria should urgently undergo exploration. Patients that do not meet these criteria may be safely observed. These observations remain true when pneumatosis intestinalis is identified and high flow oxygen therapy is not required for resolution. These patients are unlikely to benefit from antibiotics if there is no evidence of infection. Based on the experience at UPMC Horizon it is safe to manage carefully selected patients with pneumoperitoneum non-operatively. | ||||||
REFERENCES
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Author Contributions
Michael Morrison – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval for publication Sarah Brown – Acquisition of data, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published Ryan Enders – Acquisition of data, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published Ranjeet Kalsi – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published Christopher Esper – Substantial contributions to conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval for publication |
Guarantor of Submission
The corresponding author is the guarantor of submission. |
Source of Support
None |
Consent Statement
Written informed consent was obtained from the patient for publication of this case series. |
Conflict of Interest
Author declares no conflict of interest. |
Copyright
© 2018 Michael Morrison et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information. |
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