Spontaneous Pneumoperitoneum in Pediatric Patients: Dilemmas in Management

Barotrauma-Related Pneumoperitoneum in a Ventilated Child: Distinguishing Air Leak From Bowel Perforation

Pneumoperitoneum in a mechanically ventilated neonate often raises the suspicion of an acute surgical abdomen. However, barotrauma-related pneumoperitoneum resulting from alveolar rupture and air dissection into the peritoneal cavity can mimic gastrointestinal perforation. Differentiating this rare complication of positive-pressure ventilation from a true viscus perforation is essential to prevent unnecessary surgical intervention. We report a two-month-old infant born prematurely with a history of intraventricular hemorrhage and patent ductus arteriosus who presented with frequent apneic episodes, requiring mechanical ventilation at high airway pressures. Serial chest and abdominal radiographs revealed free air under the diaphragm, suggesting pneumoperitoneum. Despite radiographic evidence of potential bowel perforation, the infant remained hemodynamically stable with a soft, non-tender abdomen. A percutaneous peritoneal drain was placed for decompression, but subsequent imaging showed a right-sided pneumothorax requiring chest tube placement. An upper gastrointestinal contrast study confirmed normal bowel continuity with no evidence of perforation, supporting a diagnosis of ventilator-induced pneumoperitoneum. Conservative management-adjusting ventilator settings to reduce peak pressures and maintaining peritoneal drainage-achieved complete resolution of the pneumoperitoneum without surgical exploration. Barotrauma-induced pneumoperitoneum is an important consideration in ventilated infants who develop free intraperitoneal air. Timely recognition and a conservative approach are often sufficient when clinical and radiological findings exclude gastrointestinal perforation. Prompt diagnosis and careful ventilator management can prevent unnecessary laparotomies and optimize outcomes for these vulnerable patients.

Clinical Predictors and Outcomes for Recurrent Pneumatosis Intestinalis in Children: A Case Control Study

INTRODUCTION

Pneumatosis intestinalis (PI) is air collections within the wall of the intestine that can be associated with life threatening conditions. Recurrent episodes of PI have been reported; however, little is known about risks for recurrent disease. This study aims to identify predictors of recurrent PI and evaluate long-term outcomes in patients with recurrent PI.

METHODS

This retrospective case-control study evaluated patients, ages 6 months to 18 years, with imaging evidence of PI over a 30-month period. Images were analyzed by consensus to confirm PI. Recurrent PI was defined as new findings of PI after resolution by imaging and/or at least 1-month interval between episodes of PI. Univariate and multivariable analyses were performed using logistic regression, with significance set to P < 0.05.

RESULTS

Forty-six children were included. Recurrent PI occurred in 17 (37%) patients, with a total of 39 episodes. Predictors of recurrent PI all related to the segment of bowel involved with small bowel PI predictive of recurrent PI (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.01, 2.4) and colonic PI protective (OR 0.6; 95% CI 0.4, 0.87) after adjusting for age. Predictors for surgical intervention included cerebral palsy (OR 17; 95% CI 1.7, 167) and PI involving small bowel (OR 19; 95% 3.1, 114).

CONCLUSION

Location of PI is predictive of recurrence. Clinical outcomes were similar between groups with single episode and recurrent PI.

Idiopathic pneumoperitoneum without gastrointestinal perforation in a low-birth weight infant: A rare type of air leak syndrome

Neonatal free air on X-ray images is generally due to intestinal perforation, and requires surgical intervention. However, some cases without intestinal perforation show free air on X-ray images. Pneumoperitoneum without perforation is caused by an air leak syndrome. We present here the case of a low-birth-weight infant with free air on X-ray images, who had no evidence of intestinal perforation intraoperatively.

Air Leak Syndrome: Pneumoperitoneum in a Ventilated Neonate

Air leak syndrome has several manifestations and is common in neonates with meconium aspiration syndrome (MAS) due to air trapping. While pneumoperitoneum is classically a result of intestinal perforation, intra-abdominal free air may be a less common presentation of air leak syndrome. In the ventilated neonate, there is insufficient clinical evidence outlining management of pneumoperitoneum in this situation. We report a case of a term neonate with MAS and air leak syndrome who developed benign pneumoperitoneum (BPPT).

Tension pneumoperitoneum caused by rupture of intraabdominal soft tissue emphysema in a child supported with high-frequency oscillatory ventilation: a case report

Background

We reported a case with tension pneumoperitoneum while being on high-frequency oscillatory ventilation.

Case presentation

A 12-month-old Thai girl presented with acute respiratory distress syndrome, septic shock, and bacterial pneumonia. Although supported with mechanical ventilation, she still had severe hypoxia. She was then transitioned to high-frequency oscillatory ventilation. During a weaning period on day 7, she developed left tension pneumothorax requiring intercostal drainage and a markedly large amount of pneumoperitoneum. In spite of a bedside abdominocentesis, her abdomen was still tense and her hemodynamics was unstable. Subsequently, to exclude hollow viscus perforation, diaphragmatic injury caused by intercostal drainage, or abdominal compartment syndrome, she was transferred for surgery. There was no intestinal perforation. Postoperatively, she was on oxygen therapy, on chest physical therapy, and kept hemodynamically stable until she had recovered.

Conclusion

A case of tension pneumoperitoneum probably caused by high-frequency oscillatory ventilation was reported. Awareness of this condition should be included in the differential diagnosis.