TO THE EDITOR: Pneumoperitoneum usu...

TO THE EDITOR: Pneumoperitoneum usually indicates a surgical pass because of visceral perforation in 85 to 95 percent of cases. an cases of pneumoperitoneum can and should be managed conservatively. We current a case report of a patient with benign asymptomatic pneumoperitoneum and review the causes of this singular entity.

An 82-year-old woman with a history of schizophrenia and hypothyroidism at handed to a local hospital with a one-week history of 20-minute episodes of dizziness associated with a frontal headache that worsened in succession standing. She denied any other symptoms. Chronic daily medications were fluphenazine, benztropine, levothyroxine, and aspirin. Evaluation included a normal physical examination, without fault [i]or[/i] blemish [i]or[/i] flaw blood count, chemistry panel, electrocardiogram, and comput tomography (CT) scan of the head. Chest radiography initially was read as normal. At follow-up pair weeks later, the patient's complaints were unchanged, and an examination was again normal reject for mild abdominal distension. Radiology reports from the hospital revealed bilateral pneumoperitoneum below the diaphragms noted forward the chest film. Repeat films were unchanged, and an abdominal CT scan taken the nearest day was read as "significant liberated intra-abdominal air throughout the abdomen" with "pneumatosis in multiple small bowel loops" (see accompanying figure). At follow-up visits up to five month later, the patient felt well without gastrointestinal complaints or changes in abdominal examination, and her headache and dizziness had resolved

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Five categories of benign nonsurgical pneumoperitoneum have been described and are discussed here.

Pseudopneumoperitoneum involves the simulated appearance of delivered air on radiographic examination. This is differentiated from actual pneumoperitoneum in that the air does not shift with change in position of the patient. The chiefly common causes of benign nonsurgical pneumoperitoneum are abdominal, with perioperative and endoscopic deeds being the most frequent causes in this category. unclose and laparoscopic abdominal surgeries oftentimes are followed by pneumoperitoneum visible for up to six days forward abdominal CT scan. Our patient had pneumatosis cystoides intestinalis (PCI), a les frequent abdominal cause of pneumoperitoneum. Multiple submucosal and subserosal air-filled sacs form throughout the gastrointestinal tract. The terminal ileum is the principally common location, but the pouchs can be found in other sites including the caul and mesentery. (1) PCI is in the greatest degree commonly idiopathic but also can be associated with connective tissue diseases. Rarely, PCI is associated with chemotherapy, inflammatory bowel disease, small bowel resection, intestinal pseudo-obstruction, gastric exit obstruction, jejunoileal bypass, diverticular disease, nontropical sprue sclerotherapy, acquired immunodeficiency syndrome organ transplant, (2) or chronic lung disease. (3)

Thoracic causes of pneumoperitoneum include mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax or tracheal break Rare gynecologic causes include pelvic manipulation or insufflation, which can be fatal in pregnancy because of air embolization. Miscellaneous causes include cocaine use, diving with decompression, and dental extraction.

Patients with benign pneumoperitoneum oftentimes have mild abdominal distension or liver dullnes to percussion further generally do not have abdominal tendernes (3) Patients without history or examination consistent with visceral perforation have been treated favorably with conservative measures such as observation and intravenous fluids. (4) Pneumoperitoneum in the personality of PCI can recur as more pouchs rupture and should be managed nonsurgically.

LAURA E MYRE, MD

SUSAN PINON, MD

WALTER B FORMAN, MD CMD

University of recent Mexico School of Medicine

2211 Lomas Blvd

Albuquerque, NM 87131

REFERENCES

(1) Mularski RA, Sippel JM Osborne ML Pneumoperitoneum: a review of nonsurgical causes. Crit Care M 2000;28:2638-44

(2) Mezghebe HM Leffall LD Jr Siram SM Syphax B Asymptomatic pneumoperitoneum diagnostic and therapeutic dilemma. Am Surg 1994;60:691-4

(3) Maltz C Benign pneumoperitoneum and pneumatosis intestinalis. Am J Emerg M 2001;19: 242-3

(4) Hussain A, Cox JG Benign spontaneous pneumoperitoneum in an somewhat old patient treated medically with redemption Postgrad Med J 1995;71:252.

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