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Pneumoperitoneum is pneumatosis (abnormal presence of air or other gas) in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal viscus, generally a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

In the mid-twentieth century, an "artificial" pneumoperitoneum was sometimes intentionally administered as a treatment for a hiatal hernia. This was achieved by insufflating the abdomen with carbon dioxide. The practice is currently used by surgical teams in order to perform laparoscopic surgery.

Causes

Perforated duodenal ulcer – The most common cause of rupture in the abdomen. Especially of the anterior aspect of the first part of the duodenum.
Perforated peptic ulcer
Bowel obstruction
Ruptured diverticulum
Penetrating trauma
Ruptured inflammatory bowel disease (e.g., megacolon)
Necrotising enterocolitis/pneumatosis coli^[1]
Bowel cancer
Ischemic bowel
Steroids
After laparotomy
After laparoscopy
Breakdown of a surgical anastomosis
Bowel injury after endoscopy
Peritoneal dialysis (PD), although the prevalence of pneumoperitoneum is estimated to be less than 4% among people with PD in a more recent study in the United Kingdom.^[2]
Vaginal insufflation (air enters via the fallopian tubes; e.g., water-skiing,^[3] oral sex^[4]^[5])
Colonic or peritoneal infection
From chest (e.g., bronchopleural fistula)
Non-invasive PAP (positive airway pressure) can force air down duodenum as well as down trachea.

Diagnosis

When present, pneumoperitoneum can often be seen on projectional radiography, but small amounts are often missed, and CT scan is nowadays regarded as a criterion standard in the assessment of a pneumoperitoneum.^[6] CT can visualize quantities as small as 5 cm³ of air or gas.

Signs that can be seen on projectional radiography are the double wall sign (also called Rigler's sign) and the football sign.

The double wall sign marks the presence of air on both sides of the intestine.^[7] However, a false double wall sign can result from two loops of bowel being in contact with one another.^[8] The sign is named after Leo George Rigler. It is not the same as Rigler's triad.

The football sign is when the abdomen appears as a large oval radiolucency reminiscent of an American football on a supine projectional radiograph.^[9] The football sign is most frequently seen in infants with spontaneous or iatrogenic gastric perforation causing pneumoperitoneum. It is also seen in bowel obstruction with secondary perforation, as in Hirschprung disease, midgut volvulus, meconium ileus and intestinal atresia. Iatrogenic causes like endoscopic perforation may also give football sign.

Another pneumoperitoneum on chest X-ray.
Pneumoperitoneum seen on X-ray with the patient lying on his left side.
Double wall sign. This is a secondary sign of pneumoperitoneum. Patient is supine, and air within the abdomen and lumen of the bowel accentuate both sides of the bowel wall.
Play media

Ultrasound finding of pneumoperitoneum known as "peritoneal stripe sign"^[10]

Differential diagnosis

As differential diagnoses, a subphrenic abscess, bowel interposed between diaphragm and liver (Chilaiditi syndrome), and linear atelectasis at the base of the lungs can simulate free air under the diaphragm on a chest X-ray.

Treatment

Depends on causes

Terminology

Pneumoperitoneum can be described as peritoneal emphysema,^[11] just as pneumomediastinum can be called mediastinal emphysema, but pneumoperitoneum is the usual name.

References

^ Necrotizing Enterocolitis Bugs, Drugs and Things That Go Bump in the Night
^ Imran, M.; Bhat, R.; Anijeet, H. (2011). "Pneumoperitoneum in peritoneal dialysis patients; one centre's experience". Clinical Kidney Journal. 4 (2): 120–123. doi:10.1093/ndtplus/sfq208. ISSN 2048-8505. PMC 4421564.
^ Kizer, KW (May 1980). "Medical hazards of the water skiing douche". Ann Emerg Med. 9 (5): 268–269. PMID 7369581. Many injuries can result from water skiing accidents, but the water skiing "douche" is unique to this sport. Although generally causing only discomfort, significant trauma can result from the forceful entry of water into the various body orifices.
^ Jacobs VR, Mundhenke C, Maass N, Hilpert F, Jonat W (Oct 2000). "Sexual activity as cause for non-surgical pneumoperitoneum". JSLS. 4: 297–300. PMC 3113190. PMID 11051188.CS1 maint: Multiple names: authors list (link)
^ Cawich SO, Johnson PB, Williams E, Naraynsingh V (25 Sep 2013). "Non-surgical pneumoperitoneum after oro-genital intercourse". Int J Surg Case Rep. 4 (11): 1048–1051. PMC 3113190. PMID 24121052.CS1 maint: Multiple names: authors list (link)
^ Ali Nawaz Khan. "eMedicine.com: Pneumoperitoneum".
^ Harkin DW, Blake G. Small bowel obstruction in a young adult. Postgrad Med J. 1999 Mar;75(881):173-5. PMID 10448501. Free Full Text.
^ de Lacey G, Bloomberg T, Wignall BK. Pneumoperitoneum: the misleading double wall sign. Clin Radiol. 1977 Jul;28(4):445-8. PMID 872511.
^ Rampton JW (April 2004). "The football sign". Radiology. 231 (1): 81–2. doi:10.1148/radiol.2311011290. PMID 14990817.
^ "UOTW #68 - Ultrasound of the Week". Ultrasound of the Week. 22 March 2016. Retrieved 27 May 2017.
^ Marian, K; et al. (2015), "Spontaneous pneumoperitoneum in a patient after ventilation therapy", Pol Przegl Chir, 86 (12): 601–603, doi:10.1515/pjs-2015-0008, PMID 25803061.

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UpToDate Contents

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1. 消化管穿孔の概要 overview of gastrointestinal tract perforation
2. 小児および思春期における腹腔鏡検査の概要 overview of laparoscopy in children and adolescents
3. 婦人科腹腔鏡下手術の概要および非経臍帯的進入 overview of gynecologic laparoscopic surgery and non umbilical entry sites
4. 腹腔鏡下手術に用いる腹部アクセス法 abdominal access techniques used in laparoscopic surgery
5. 腹腔鏡下手術の合併症 complications of laparoscopic surgery

English Journal

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery.

Cinnella G, Grasso S, Spadaro S, Rauseo M, Mirabella L, Salatto P, Capraris AD, Nappi L, Greco P, Dambrosio M.SourceProfessor of Anesthesia and Intensive Care, ‡ Resident of Anesthesia and Intensive Care, § Fellow Anesthesiologist, ‖ Staff Anesthesiologist, # Assistant Professor of Anesthesia and Intensive Care, ‡‡ Professor of Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, ** Professor of Gynecology, †† Assistant Professor of Gynecology, Department of Gynecology, University of Foggia, Foggia, Italy. † Assistant Professor of Anesthesia and Intensive Care, Department of Anesthesia and Intensive Care, University of Bari, Bari, Italy.
Anesthesiology.Anesthesiology.2013 Jan;118(1):114-122.
BACKGROUND:: The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by incre
PMID 23196259

Cerebral Oxygenation during Laparoscopic Surgery: Jugular Bulb versus Regional Cerebral Oxygen Saturation.

Choi SH, Kim SH, Lee SJ, Soh SR, Oh YJ.SourceDepartment of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea. yjoh@yuhs.ac.
Yonsei medical journal.Yonsei Med J.2013 Jan 1;54(1):225-30. doi: 10.3349/ymj.2013.54.1.225.
Purpose: We hypothesized that regional cerebral oxygen saturation (rSO2) could replace jugular bulb oxygen saturation (SjvO2) in the steep Trendelenburg position under pneumoperitoneum. Therefore, we evaluated the relationship between SjvO2 and rSO2 during laparoscopic surgery. Materials and Methods
PMID 23225824

Japanese Journal

腹腔鏡下手術と開腹手術における気管チューブのカフ圧変化の持続的モニタリング

麻酔 = The Japanese journal of anesthesiology : 日本麻酔科学会準機関誌 67(10), 1036-1039, 2018-10
NAID 40021694163

Anesthetic management and associated complications of peroral endoscopic myotomy: A case series

World Journal of Gastrointestinal Endoscopy 10(9), 193-199, 2018-09-16
NAID 120006532021

低心機能患者の腹腔鏡手術の周術期管理

麻酔 = The Japanese journal of anesthesiology : 日本麻酔科学会準機関誌 67(8), 872-877, 2018-08
NAID 40021644576

Related Pictures

★リンクテーブル★

リンク元	「腹膜性鼓腸」「気腹」「気腹症」「腹腔気腫」

「腹膜性鼓腸」

Classification	D ICD-10: K66.8; ICD-9-CM: 568.89, 770.2; MeSH: D011027; DiseasesDB: 31511;
External resources	eMedicine: radio/562;

Pneumoperitoneum
	Frontal chest X-ray. The air bubble below the right hemidiaphragm (on the left of the image) is a pneumoperitoneum.
Specialty	Gastroenterology