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