Skip to main content
PMC home page
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 1997 Sep;73(863):531–537. doi: 10.1136/pgmj.73.863.531

Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas.

N M Williams 1, D F Watkin 1
PMCID: PMC2431444  PMID: 9373590

Abstract

Intraperitoneal free gas seen radiologically as air under the diaphragm nearly always indicates a perforated abdominal viscus that requires surgical intervention. Rarely, however, the presence of a pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. Such a situation is termed spontaneous or nonsurgical pneumoperitoneum. In this review, we explore the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. An appreciation of the condition and its likely aetiological factors should improve awareness and possibly reduce the imperative to perform an emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.

Full text

PDF
534

Images in this article

531Figure 1
on p.531
532Figure 2
on p.532

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Altman A. R., Johnson T. H. Pneumoperitoneum and pneumoretroperitoneum. Consequences of positive end-expiratory pressure therapy. Arch Surg. 1979 Feb;114(2):208–211. doi: 10.1001/archsurg.1979.01370260098017. [DOI] [PubMed] [Google Scholar]
  2. Aranda J. V., Stern L., Dunbar J. S. Pneumothorax with pneumoperitoneum in a newborn infant. Am J Dis Child. 1972 Feb;123(2):163–166. doi: 10.1001/archpedi.1972.02110080141021. [DOI] [PubMed] [Google Scholar]
  3. Bar-Meir S., Lang A., Shemesh E., Nass S., Dreznick Z. Pneumoperitoneum after insertion of endoscopic biliary stent for post-cholecystectomy biliary leak. Gastrointest Endosc. 1993 Nov-Dec;39(6):818–820. doi: 10.1016/s0016-5107(93)70275-8. [DOI] [PubMed] [Google Scholar]
  4. Bourne M. H., Watson R. C., Carmichael S. W. Pneumoperitoneum as a complication of carbon dioxide knee arthroscopy. A case report. Am J Sports Med. 1993 Jul-Aug;21(4):623–625. doi: 10.1177/036354659302100424. [DOI] [PubMed] [Google Scholar]
  5. Cass L. J., Dow E. C., Brooks J. R. Pneumoperitoneum following pelvic examination. Am J Gastroenterol. 1966 Mar;45(3):209–211. [PubMed] [Google Scholar]
  6. Chandler J. G., Berk R. N., Golden G. T. Misleading pneumoperitoneum. Surg Gynecol Obstet. 1977 Feb;144(2):163–174. [PubMed] [Google Scholar]
  7. Christie J. P., Marrazzo J., 3rd "Mini-perforation" of the colon--not all postpolypectomy perforations require laparotomy. Dis Colon Rectum. 1991 Feb;34(2):132–135. doi: 10.1007/BF02049986. [DOI] [PubMed] [Google Scholar]
  8. Clinch S. L., Thompson J. S., Edney J. A. Pneumoperitoneum after cardiopulmonary resuscitation: a therapeutic dilemma. J Trauma. 1983 May;23(5):428–430. doi: 10.1097/00005373-198305000-00013. [DOI] [PubMed] [Google Scholar]
  9. DODEK S. M., FRIEDMAN J. M. Spontaneous pneumoperitoneum. Obstet Gynecol. 1953 Jun;1(6):689–698. [PubMed] [Google Scholar]
  10. Daly B. D., Guthrie J. A., Couse N. F. Pneumoperitoneum without peritonitis. Postgrad Med J. 1991 Nov;67(793):999–1003. doi: 10.1136/pgmj.67.793.999. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Darke S. G., Bloomfield E. Case of complete gastric rupture complicating resuscitation. Br Med J. 1975 Aug 16;3(5980):414–415. doi: 10.1136/bmj.3.5980.414. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. FREEARK R. J., RAFFENSPER GER J. G., CONDON J. B. Pneumoperitoneum in infancy. Surg Gynecol Obstet. 1961 Nov;113:623–630. [PubMed] [Google Scholar]
  13. Freeman R. K. Pneumoperitoneum from oral-genital insufflation. Obstet Gynecol. 1970 Jul;36(1):162–164. [PubMed] [Google Scholar]
  14. GREENBERG L. F., KAHN S. B. Klebsiella pneumonia with pneumothorax, pneumomediastinum and pneumoperitoneum. Dis Chest. 1963 May;53:546–550. doi: 10.1378/chest.43.5.546. [DOI] [PubMed] [Google Scholar]
  15. Gantt C. B., Jr, Daniel W. W., Hallenbeck G. A. Nonsurgical pneumoperitoneum. Am J Surg. 1977 Sep;134(3):411–414. doi: 10.1016/0002-9610(77)90418-4. [DOI] [PubMed] [Google Scholar]
  16. Glauser F. L., Bartlett R. H. Pneumoperitoneum in association with pneumothorax. Chest. 1974 Nov;66(5):536–540. doi: 10.1378/chest.66.5.536. [DOI] [PubMed] [Google Scholar]
  17. Gordon H. L., Walkup J. L. Scrotal pneumatocele as an unusual sign of pneumoperitoneum: report of a case and review of the literature. J Urol. 1970 Sep;104(3):441–442. doi: 10.1016/s0022-5347(17)61755-5. [DOI] [PubMed] [Google Scholar]
  18. Gottfried E. B., Plumser A. B., Clair M. R. Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study. Gastrointest Endosc. 1986 Dec;32(6):397–399. doi: 10.1016/s0016-5107(86)71919-6. [DOI] [PubMed] [Google Scholar]
  19. Grosfeld J. L., Boger D., Clatworthy H. W., Jr Hemodynamic and manometric observations in experimental air-block syndrome. J Pediatr Surg. 1971 Jun;6(3):339–344. doi: 10.1016/0022-3468(71)90476-3. [DOI] [PubMed] [Google Scholar]
  20. HARRISON I., LITWER H., GERWIG W. H., Jr Studies on the incidence and duration of postoperative pneumoperitoneum. Ann Surg. 1957 Apr;145(4):591–594. doi: 10.1097/00000658-195704000-00019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hall C., Dorricott N. J., Donovan I. A., Neoptolemos J. P. Colon perforation during colonoscopy: surgical versus conservative management. Br J Surg. 1991 May;78(5):542–544. doi: 10.1002/bjs.1800780509. [DOI] [PubMed] [Google Scholar]
  22. Halsall A. K., Benson E. A. Pneumoperitoneum following hernia repair. Br J Surg. 1978 Jun;65(6):416–416. doi: 10.1002/bjs.1800650614. [DOI] [PubMed] [Google Scholar]
  23. Hill H. F., Bunting J., Wood R. D., Temple J. G. The significance of radiological pneumoperitoneum in the diagnosis of postoperative peritonitis. J R Coll Surg Edinb. 1978 Sep;23(5):303–304. [PubMed] [Google Scholar]
  24. Hoover E. L., Cole G. D., Mitchell L. S., Adams C. Z., Jr, Hassett J. Avoiding laparotomy in nonsurgical pneumoperitoneum. Am J Surg. 1992 Aug;164(2):99–103. doi: 10.1016/s0002-9610(05)80363-0. [DOI] [PubMed] [Google Scholar]
  25. Hussain A., Cox J. G. Benign spontaneous pneumoperitoneum in an elderly patient treated medically with recovery. Postgrad Med J. 1995 Apr;71(834):252–252. doi: 10.1136/pgmj.71.834.252-a. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Jash D. K. An unusual complication during adeno-tonsillectomy. J Laryngol Otol. 1973 Feb;87(2):191–194. doi: 10.1017/s0022215100076799. [DOI] [PubMed] [Google Scholar]
  27. KEYTING W. S., MCCARVER R. R., KOVARIK J. L., DAYWITT A. L. Pneumatosis intestinalis: a new concept. Radiology. 1961 May;76:733–741. doi: 10.1148/76.5.733. [DOI] [PubMed] [Google Scholar]
  28. KOSS L. G. Abdominal gas cysts (pneumatosis cystoides intestinorum hominis); an analysis with a report of a case and a critical review of the literature. AMA Arch Pathol. 1952 Jun;53(6):523–549. [PubMed] [Google Scholar]
  29. Krausz M., Manny J. Pneumoperitoneum associated with pneumothorax: a surgical dilemma in the post-traumatic patient. J Trauma. 1977 Mar;17(3):238–240. [PubMed] [Google Scholar]
  30. Kumar A., Pontoppidan H., Falke K. J., Wilson R. S., Laver M. B. Pulmonary barotrauma during mechanical ventilation. Crit Care Med. 1973 Jul-Aug;1(4):181–186. doi: 10.1097/00003246-197307000-00001. [DOI] [PubMed] [Google Scholar]
  31. LOZMAN H., NEWMAN A. J. Spontaneous pneumoperitoneum occurring during postpartum exercises in the knee-chest position. Am J Obstet Gynecol. 1956 Oct;72(4):903–905. doi: 10.1016/0002-9378(56)90181-8. [DOI] [PubMed] [Google Scholar]
  32. Leininger B. J., Barker W. L., Langston H. T. Tension pneumoperitoneum and pneumothorax in the newborn. Ann Thorac Surg. 1970 Apr;9(4):359–363. doi: 10.1016/s0003-4975(10)65520-8. [DOI] [PubMed] [Google Scholar]
  33. Leonidas J. C., Hall R. T., Rhodes P. G., Amoury R. A. Pneumoperitoneum in ventilated newborns: a medical or a surgical problem? Am J Dis Child. 1974 Nov;128(5):677–680. doi: 10.1001/archpedi.1974.02110300087011. [DOI] [PubMed] [Google Scholar]
  34. Leys D. Pneumoperitoneum. Br Med J. 1944 Oct 28;2(4373):562–563. doi: 10.1136/bmj.2.4373.562. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Madura M. J., Craig R. M., Shields T. W. Unusual causes of spontaneous pneumoperitoneum. Surg Gynecol Obstet. 1982 Mar;154(3):417–420. [PubMed] [Google Scholar]
  36. Matsuyama S., Satoh H., Yunotani S., Mashima H., Haraoka S., Harada S., Hisatsugu T. An unusual presentation of spontaneous pneumoperitoneum secondary to the rupture of a gas-containing pyogenic liver abscess: report of a case. Surg Today. 1994;24(1):63–66. doi: 10.1007/BF01676888. [DOI] [PubMed] [Google Scholar]
  37. McGlone F. B., Vivion C. G., Jr, Meir L. Spontaneous penumoperitoneum. Gastroenterology. 1966 Sep;51(3):393–398. [PubMed] [Google Scholar]
  38. Mezghebe H. M., Leffall L. D., Jr, Siram S. M., Syphax B. Asymptomatic pneumoperitoneum diagnostic and therapeutic dilemma. Am Surg. 1994 Sep;60(9):691–694. [PubMed] [Google Scholar]
  39. NELSON P. K. Pulmonary gas embolism in pregnancy and the puerperium. Obstet Gynecol Surv. 1960 Aug;15:449–481. doi: 10.1097/00006254-196008000-00001. [DOI] [PubMed] [Google Scholar]
  40. O'Brien W. J., Ryckman F. C. Catheter-induced urinary bladder rupture presenting with pneumoperitoneum. J Pediatr Surg. 1994 Oct;29(10):1397–1398. doi: 10.1016/0022-3468(94)90126-0. [DOI] [PubMed] [Google Scholar]
  41. PAPP J. P., SULLIVAN B. H., Jr SPONTANEOUS PNEUMOPERITONEUM WITHOUT PERITONITIS; REPORT OF A CASE. Cleve Clin Q. 1965 Jul;32:149–155. doi: 10.3949/ccjm.32.3.149. [DOI] [PubMed] [Google Scholar]
  42. PORTER A. Spontaneous pneumoperitoneum in the newborn; report of a case. N Engl J Med. 1956 Apr 12;254(15):694–696. doi: 10.1056/NEJM195604122541504. [DOI] [PubMed] [Google Scholar]
  43. Pieterse A. S., Leong A. S., Rowland R. The mucosal changes and pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol. 1985 Jul;16(7):683–688. doi: 10.1016/s0046-8177(85)80152-0. [DOI] [PubMed] [Google Scholar]
  44. Poilly J. N. Pneumoperitoneum associated with Escherichia coli peritonitis: a report of two cases. Postgrad Med J. 1970 Feb;46(532):114–116. doi: 10.1136/pgmj.46.532.114. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Powner D. J., Snyder J. V., Morris C. W., Grenvik A. Retroperitoneal air dissection associated with mechanical ventilation. Chest. 1976 Jun;69(6):739–742. doi: 10.1378/chest.69.6.739. [DOI] [PubMed] [Google Scholar]
  46. Rose D. M., Jarczyk P. A. Spontaneous pneumoperitoneum after scuba diving. JAMA. 1978 Jan 16;239(3):223–223. [PubMed] [Google Scholar]
  47. Samach M., Brandt L. J., Bernstein L. H. Spontaneous pneumoperitoneum with Pneumatosis cystoides intestinalis in a patient with mixed connective tissue disease. Am J Gastroenterol. 1978 Apr;69(4):494–500. [PubMed] [Google Scholar]
  48. Sandler C. M., Libshitz H. I., Marks G. Pneumoperitoneum, pneumomediastinum and pneumopericardium following dental extraction. Radiology. 1975 Jun;115(3):539–540. doi: 10.1148/15.3.539. [DOI] [PubMed] [Google Scholar]
  49. Schnall H. A., Falkenstein D. B., Raicht R. F. Persistent pneumoperitoneum after percutaneous endoscopic gastrostomy. Gastrointest Endosc. 1987 Jun;33(3):248–250. doi: 10.1016/s0016-5107(87)71573-9. [DOI] [PubMed] [Google Scholar]
  50. Smith L. E., Nivatvongs S. Complications in colonoscopy. Dis Colon Rectum. 1975 Apr;18(3):214–220. doi: 10.1007/BF02587277. [DOI] [PubMed] [Google Scholar]
  51. Spaulding L. B., Gallup D. G. Pneumoperitoneum after hysterectomy. JAMA. 1979 Feb 23;241(8):825–825. [PubMed] [Google Scholar]
  52. Svetvilas C., Tannenberg A. M. Pneumoperitoneum with peritoneal dialysis. Lancet. 1971 May 1;1(7705):910–911. doi: 10.1016/s0140-6736(71)92469-x. [DOI] [PubMed] [Google Scholar]
  53. TOWBIN M. N. Mediastinal emphysema occurring with therapeutic pneumoperitoneum; report of ten cases. Ann Intern Med. 1951 Sep;35(3):555–592. doi: 10.7326/0003-4819-35-3-555. [DOI] [PubMed] [Google Scholar]
  54. Tabrisky J., Mallin L. P., Smith J. A., 3rd Pneumoperitoneum after coitus. A complication due to uterine tube prolapse after vaginal hysterectomy. Obstet Gynecol. 1972 Aug;40(2):218–220. [PubMed] [Google Scholar]
  55. Thirumahilmaran S., Patel N., Thomas E. Prolonged benign pneumoperitoneum after percutaneous endoscopic gastrostomy. Am J Gastroenterol. 1995 Jan;90(1):147–148. [PubMed] [Google Scholar]
  56. Varon J., Laufer M. D., Sternbach G. L. Recurrent pneumoperitoneum following vaginal insufflation. Am J Emerg Med. 1991 Sep;9(5):447–448. doi: 10.1016/0735-6757(91)90211-2. [DOI] [PubMed] [Google Scholar]
  57. Watson D. I., Isaacs J., Williams R. S. Emphysematous cholecystitis can cause pneumoperitoneum. Aust N Z J Surg. 1994 Feb;64(2):130–131. doi: 10.1111/j.1445-2197.1994.tb02161.x. [DOI] [PubMed] [Google Scholar]
  58. YLVISAKER R. S., MYHRE J. Management of pneumoperitoneum after gastroscopy. Gastroenterology. 1951 Jul;18(3):463–465. [PubMed] [Google Scholar]
  59. Zerella J. T., McCullough J. Y. Pneumoperitoneum in infants without gastrointestinal perforation. Surgery. 1981 Feb;89(2):163–167. [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES