Pneumoperitoneum and pneumoretroperitoneum in blunt trauma patients

Abdominal trauma

Traumatic injuries are the leading cause of death in people aged<45 years, and abdominal trauma is a source of significant morbidity and mortality and high economic costs. Imaging has a fundamental role in abdominal trauma, where CT is a fundamental tool for rapid, accurate diagnosis that will be key for patients' clinical outcomes.

Delayed retropneumoperitoneum following vaginal laceration in a 7-year-old girl

We describe an unusual case of delayed retropneumoperitoneum caused by a deep vaginal laceration as a result trauma from a water jet in a fountain. A 7-year-old premenarcheal girl presented to the emergency department after experiencing an injury from a water jet at a fountain park. Initially, the patient's vital sign and perineum were within normal range. Because the patient's vital signs became unstable 12 hours after vaginal injury, we carried out abdomino-pelvic computed tomography resulting in retropneumoperitoneum. Arterial bleeding from vaginal lateral wall was founded and controlled by electrocoagulation. No damage to the rectum was laparoscopically confirmed. A diagnostic laparoscopy, not laparotomy, should be considered in cases of retropneumoperitoneum with an ambiguous cause first.

Blunt trauma resulting in pneumothorax with progression to pneumoperitoneum: a unique diagnosis with predicament in management

Here, we present a case of pneumoperitoneum caused by traumatic pneumothorax after a fall. The patient is an 82-year-old male who was brought into the emergency department after being found at the bottom of a flight of stairs with a bleeding scalp laceration. Upon presentation, the patient underwent emergent intubation followed by tube thoracostomy placement, had necessary imaging and was transferred to the surgical intensive care unit (SICU). Imaging revealed signs of pneumomediastinum and pneumoperitoneum in addition to the partially resolved pneumothorax. In the SICU, the patient became hemodynamically unstable requiring vasopressor support, which in the face of documented pneumoperitoneum without a clear cause mandated exploration. He was taken to the operating room for suspected viscus perforation, though none was found after extensively searching during an exploratory laparotomy. We suspect the patient developed pneumomediastinum and pneumoperitoneum as a result of traumatic pneumothorax, hastened by his subsequent intubation and mechanical ventilation.

Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital

INTRODUCTION

Computed tomography (CT) scan has increasingly become the diagnostic modality of choice for the evaluation of patients with blunt abdominal trauma. CT scan is highly sensitive in the detection of small amounts of free intraperitoneal air (FIA). We aimed to evaluate the usefulness of FIA detected by CT scan in diagnosing bowel perforation in blunt trauma patients.

PATIENTS AND METHODS

All abdominal CT scans of blunt trauma patients who were treated at Al Rahba Hospital during the period from October 2010 till December 2013 were retrospectively reviewed. The results of abdominal CT scan were compared with the clinical follow up and operative findings to evaluate the sensitivity, specificity, predictive values, and usefulness index of CT-detected FIA in diagnosing bowel perforation.

RESULTS

Abdominal CT scans were performed for 419 trauma patients. 21 (5%) patients were found to have FIA, two of them were true positive (10%), six (29%) needed mechanical ventilation, and eleven (52%) had a pneumothorax. 15/21 (71%) patients had multiple FIA pockets; the median (range) was 3 (2-10) air pockets. Two patients with multiple air pockets of 10mm-thick cuts or more had small bowel perforation. Six (29%) patients had a single air pocket of less than 10mm and none had bowel perforation. 398 patients had negative CT scan for FIA; two of them were false negative. CT-detected FIA scan had a sensitivity of 50% (95% CI: 6.8%-93.2%), specificity of 95.4% (95% CI: 92.9%-97.2%.), a positive predictive value of 9.5% (95% CI: 1.2%-30.4%) and a negative predictive value of 99.5% (95% CI: 98.2%-99.9%) for detecting bowel perforation. The usefulness index for abdominal CT scan FIA for detecting bowel perforation was 0.23 (not useful).

CONCLUSIONS

Our study which stemmed from a community-based hospital showed that free intraperitoneal air found on abdominal CT scan of blunt trauma patients was an unreliable radiological finding for bowel perforation. The decision for laparotomy should be based on combined clinical and radiological findings. Conservative management with active observation may avoid unnecessary laparotomy.

Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma

INTRODUCTION

Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen.

PRESENTATION OF CASE

We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed.

CONCLUSION

Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.

Nonsurgical pneumoperitoneum in a dog secondary to blunt force trauma to the chest

OBJECTIVE

To describe the medical management of pneumoperitoneum without surgical intervention in a dog that sustained blunt force trauma to the thorax. To review the mechanisms of how a thoracic injury (ie, extra-abdominal source) can lead to pneumoperitoneum.

CASE SUMMARY

A 4-month-old Shih Tzu puppy was attacked by a larger dog and sustained various injuries including a pneumothorax, pneumomediastinum, and a pneumoperitoneum. The dog presented minimally responsive and in respiratory distress secondary to pulmonary contusions and noncardiogenic pulmonary edema. No penetrating wounds to the abdomen or thorax were identified. As no immediate surgical lesion was identified the dog was treated conservatively without the need for surgical intervention. The dog was successfully managed and discharged after a few days of supportive care with oxygen therapy. Before discharge, repeat radiographs revealed complete resolution of the pneumothorax, pneumomediastinum, and pneumoperitoneum.

NEW OR UNIQUE INFORMATION PROVIDED

Cases of nonsurgical pneumoperitoneum have rarely been reported in the veterinary literature. A thoracic source of pneumoperitoneum should be considered when the suspicion of a ruptured viscus is low based on diagnostic procedures (eg, ultrasound, computed tomography, and diagnostic peritoneal lavage), in addition to physical examination (eg, lack of fever and absence of abdominal pain) and laboratory findings (eg, absence of inflammatory leukogram).

Tubo-ovarian abscess presenting as pneumoperitoneum

BACKGROUND

Tubo-ovarian abscess (TOA), a serious complication of pelvic inflammatory disease, often require the antibiotic administration, surgical resection or the transvaginal aspiration. Pneumoperitoneum is often associated with the bowel perforation. We reported one case with TOA and pneumoperitoneum that have been mistaken for a perforated bowel with concomitant adnexal mass.

CASE

A 30-year-old diabetic Chinese woman was transferred for diffused abdominal pain, mild fever, nausea, and low-grade fever for 5 days. The sonography revealed a 5-cm adnexal mass. The chest X-rays revealed the pneumoperitoneum. Under the impression of bowel perforation and concomitant adnexal cyst, the emergent laparotomy was performed and the TOA was resected. No evidence of gastrointestinal perforation was present. Culture studies showed Escherichia coli without other bacteria flora. The postoperative course was uneventful.

CONCLUSION

We concluded that, beside the bowel perforation, TOA should be considered when a diabetic woman presents with pneumoperitoneum and adnexal mass.