eMedicine Specialties > Radiology > Gastrointestinal

Pneumoperitoneum: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; Muthusamy Chandramohan, MBBS, DMRD, FRCR, Consultant Radiologist, Bradford Teaching Hospitals, UK
Contributor Information and Disclosures

Updated: Jun 18, 2008

Intervention

Radiologic intervention has no role unless it occurs during radiologic procedures such as pneumatic reduction of intussusception in pediatric patients.

Medicolegal Pitfalls

  • Iatrogenic perforation may occur in newborns and in infants as a result of misplaced tubes and vigorous resuscitation efforts. Some perforations may be drug related. Caution is therefore required in dealing with infants.
  • The use of ionic contrast material in evaluating a perforated abdominal viscus should be avoided in ill patients who are at risk for inhaling the contrast medium. This may cause life-threatening pulmonary edema.
  • Blunt abdominal trauma may lead to a bowel perforation, which may go unrecognized in complex injury, particularly blast injuries and injuries related to motor vehicle accidents. Blunt abdominal trauma usually affects a loop of small bowel, where the bowel is compressed against the vertebral column and the aorta, resulting in a burst-type injury. The resultant peritoneal spillage usually leads to the early onset of peritonitis. Bowel contusion and perforation must be differentiated because the latter usually requires surgery.
  • Mortality associated with a perforated peptic ulcer largely depends on how quickly the ulcer is sutured after perforation. Surgery performed within a few hours has virtually zero mortality. If the clinical presentation is characteristic, imaging may only delay the patient's treatment. An appreciable number of gastric perforations are caused by a gastric carcinoma, making a stronger case for performing immediate partial gastrectomy in these patients.
  • Gastric perforation is a rare complication of endoscopy. Initially, few signs may be seen because the patient is under sedation. Eventually, as the effect of the medication wears off, the patient may develop an acute abdomen.
  • In infants and the elderly, the incidence of perforation from an acute appendicitis is greater than in other patients. In infants, the patients may provide only an incomplete history; the picture is usually that of a toxic child who resists abdominal examination. Diffuse peritonitis may develop rapidly from an appendix perforation in a child. In the elderly, the development of perforation and diffuse peritonitis is also greater with appendicitis; diagnosis may be delayed because elderly persons may disregard the symptoms. In the very young and very old, a high index of clinical suspicion is required to avoid errors in diagnosis and treatment.
  • Perforation is a rare complication of a barium enema study. Some perforations occur as a result of faulty technique, whereas others are associated with a diseased bowel. Perforations may also occur in infants and children.
  • Occasionally, perforation occurs in association with the with escape of air into the soft tissues, with no escape of barium. Intraperitoneal spillage of barium is a serious complication, with a mortality rate greater than 50%. Perforation during a barium enema study appears to be more lethal than perforation during proctosigmoidoscopy or colonoscopy. Therefore, when dealing with a bowel with questionable viability, one should be cautious in performing a barium enema study; use of a water-soluble contrast agent should be considered.
  • Tension pneumoperitoneum may result from an abdominal viscus perforation, blunt abdominal trauma, bowel surgery, or air tracking down from the thorax (such as from a pneumothorax). It is characterized by rapidly increasing intra-abdominal pressure with potentially fatal hemodynamic consequences. Prompt abdominal surgery and the identification of possible sites of perforation are usually advocated. In a newborn, respiratory distress may be the presenting feature of a tension pneumoperitoneum.
  • Carbon dioxide tension pneumoperitoneum can be deliberately induced in preparation for laparoscopic surgery. Newer laparoscopic techniques that were initially used in younger patients are now being used in elderly patients. These patients often have comorbidities in the form of respiratory or cardiac disease. The major complications of laparoscopic surgery are related to the cardiorespiratory effects of pneumoperitoneum. Therefore, potential cardiorespiratory problems in these patients need tailored anesthetic care.

Special Concerns

  • Most pregnant women (90%) experience significant improvement or complete resolution of peptic ulcer disease. Complications of peptic ulcer disease such as hemorrhage and perforation are rare in pregnancy.
  • Radiology has a role in the evaluation of suspected perforation.
  • US is readily available in most centers and can be used in the pregnant patient.
  • The use of conventional radiography involves irradiation of the fetus.
    • In a series of 100 patients, Woodring and Heiser found that use of upright lateral chest radiographs led to a confirmation of pneumoperitoneum in 98% of patients.37 By contrast, use of standard upright posteroanterior (PA) radiographs resulted in a confirmation in only 80% of patients. This suggests that upright lateral views are more sensitive than standard upright PA chest radiographs.
    • With lateral chest radiography, the fetus is excluded from the direct beam.
    • Negative findings support conservative management.
    • For cases in which there is strong clinical suspicion but the radiographic findings are negative, the decision to use further imaging such as CT or to perform surgical exploration must be made on an individual basis.
    • Although a negative lateral chest radiograph excludes a pneumoperitoneum in most cases, the physician should not hesitate to perform a full abdominal series when the index of clinical suspicion is high. In such instances, the benefit outweighs the disadvantage of the small radiation dose to the fetus.
 


More on Pneumoperitoneum

Overview: Pneumoperitoneum
Imaging: Pneumoperitoneum
Follow-up: Pneumoperitoneum
Multimedia: Pneumoperitoneum
References
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References

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Further Reading

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Keywords

perforated abdominal viscus, air in the peritoneal cavity, peritoneal air, perforated ulcer, peptic ulcer, pneumatosis coli

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Muthusamy Chandramohan, MBBS, DMRD, FRCR, Consultant Radiologist, Bradford Teaching Hospitals, UK
Disclosure: Nothing to disclose.

Medical Editor

Neela Lamki, MD, Professor, Department of Radiology, Sultan Qaboos University, Oman; Adjunct Professor, Department of Radiology, Baylor College of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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