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Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 66, Num. 2, 2004, pp. 112-113

Indian Journal of Surgery, Vol. 66, No. 2, Mar-Apr, 2004, pp. 112-113

Case Report

Benign pneumoperitoneum following road accident: A case report

Utpal De, Krishna Kamal De, Sushil Ranjan Ghosal

Department of Surgery, Burdwan Medical College, Burdwan, West Bengal, India.
Address for correspondence: Dr. Utpal De, K-1/3, Phase-2A, Dankuni Housing Complex, Dankuni, Hooghly - 722101, India. E-mail: utpalde@vsnl.net

Paper Received: July 2003. Paper Accepted: October 2003. Source of Support: Nil.

Code Number: is04029

ABSTRACT

A 42-year-old male patient a victim of road accident developed pneumothorax which was successfully treated with an intercostal drainage. On the third day he developed sudden abdominal distension with rigidity. X-ray abdomen revealed free gas under both domes of the diaphragm. At laparotomy a thorough search did not reveal any hollow organ injury.

Key words Spontaneous pneumoperitoneum, benign pneumoperitoneum.

How to cite this article: De U, De KK, Ghosal SR. Benign pneumoperitoneum following road accident: A case report. Indian J Surg 2004;66:112-3.

A 42-year-old male patient was admitted to the casualty department with history of road accident. At the time of admission, the patient was semiconscious and in severe respiratory distress. On examination, the patient was severely anaemic and dehydrated. The pulse was feeble, blood pressure 90/50 mm Hg, with cold and clammy extremities. Examination revealed left-sided fracture shaft femur, right-sided Colle's fracture and an 8-cm linear scalp wound over the right temporal region. There were numerous cuts and grazes all over the body. His Glasgow coma scale was 10/15. Chest examination revealed resonant percussion note with tracheal deviation to the right and diminished breath sounds of the left chest. The abdomen was soft and bowel sounds were audible. The examination of the other systems was within normal limits.

The patient was resuscitated with intravenous fluids, blood and broad-spectrum antibiotics. X-ray chest revealed left-sided pneumothorax. CT scan of the brain was within normal limits except scalp haematoma over the right temporal region. USG abdomen did not reveal any significant abnormality. The haematological and biochemical examination were within normal limits.

An emergency left intercostal drain was inserted, the scalp wound was repaired and POP back slab and Thomas splint was applied to the fractured bones. The patient was shifted to the surgical intensive care unit and was kept under continuous monitoring. The patient recovered. Chest drain was removed after 48 hours following complete lung expansion on check X-ray and the patient was shifted to the surgical ward. On the third day after admission he developed sudden abdominal distension with board-like rigidity. There was no history of vomiting. Classical rebound tenderness was absent and bowel sounds were audible. Liver dullness was obliterated. His general parameters were stable. Straight X-ray abdomen revealed free gas under both domes of the diaphragm (Figure 1). A diagnosis of hollow viscous perforation was made and the patient was put up for operation. At laparotomy, barring a "pop" sound of gushing air, no evidence of any hollow viscous perforation or peritoneal fluid was evident. A thorough search after mobilizing the duodenum and colon also did not reveal any significant abnormality. The solid abdominal organs were normal.

Leaving a drain in the pelvis the abdomen was closed in layers. There was no drainage from the abdominal drain, which was removed on the third postoperative day. The patient recovered without any complications and was discharged on the seventh postoperative day after stitch removal with advice to attend orthopaedic outpatient department (OPD) for further management and surgical OPD for follow-up. At one year follow-up the patient is well without complications.

DISCUSSION

Spontaneous pneumoperitoneum occurs as a result of perforation of a hollow viscous. Rarely, true pneumoperitoneum without hollow viscous perforation may result from diffusion of thorax-derived air through a phrenic defect or along sheaths of mediastinal blood vessels.1 The female genital tract represents another route for intraperitoneal air penetration.2 Other aetiologies include iatrogenic pneumoperitoneum (after abdominal surgery and digestive endoscopy) and pneumatosis cystoides intestinalis, when the subserous intraparietal gaseous bubbles rupture into the peritoneal cavity.2 The finding of pneumoperitoneum without perforation of the digestive tract is a relatively

rare finding. About 10% of the radiological pneumoperitoneums occur without hollow viscous perforation.3 It creates a diagnostic perplexity. Pneumoperitoneum, preceded by a reasonable incidental cause in a patient with adequate abdominal examination, may warrant continued observation thus avoiding an unnecessary laparotomy.

Though in most cases the standard treatment is surgical, one should keep in mind this rare condition and adopt a more rational treatment approach avoiding unnecessary operation in case of "benign" pneumoperitoneum.4

REFERENCES

  1. Van Gelder HM, Allen KB, Renz B, Sherman R. Spontaneous pneumoperitoneum. A surgical dilemma. Am Surg 1991;57:151-6.
  2. Wolloch Y, Dintsman M, Zer M. "Spontaneous" neumoperitoneum. Am J Proctol Gastroenterol Colon Rectal Surg 1978;29:35-8.
  3. Rege SA, Philip U, Quentin N, Deolekar S, Rohandia O. Ruptured splenic abscess presenting as pneumoperitoneum. Indian J Gastroenterol 2001;20:246-7.
  4. Lovecek M, Herman J, Svach I, Gryga A, Duda M. Postcoital pneumoperitoneum after hysterectomy. Surg Endosc 2001;15:98.

© 2004 Indian Journal of Surgery.


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