Review

Pneumoperitoneum: A review of nonsurgical causes

Richard A. Mularski, MD; Jeffrey M. Sippel, MD, MPH; Molly L. Osborne, MD, PhD

Objective: To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate. Data Source: We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identied 482 articles by using these keywords and reviewed all articles. Additional articles were identied and selectively reviewed by using key words laparotomy, laparoscopy, and complications. Study Selection: We reviewed all case reports and reviews of NSP, dened as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy. Data Synthesis: Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

Conclusions: Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases. (Crit Care Med 2000; 28: 2638 2644) KEY WORDS: pneumoperitoneum; benign; nonsurgical; spontaneous; iatrogenic; barotrauma; pneumatosis; diaphragmatic defects; free air; mechanical ventilation; gynecological; laparotomy; laparoscopy; complications

neumoperitoneum, or air within the peritoneal cavity, frequently indicates a perforated abdominal viscus that requires emergent surgical management. Pneumoperitoneum appears as a characteristic radiolucency seen below the diaphragm on chest radiograph or in a superiorly dependent location on abdominal radiograph. In the appropriate clinical setting, the radiographic presence of intraperitoneal air often is believed to be a diagnostic nding (1). In fact, pneumoperitoneum reects visceral perforation in 85% to 95% of all occurrences (2 4). In 5% to 15% of cases, however, pneumoperitoneum does not reect perforation and results from another source that does not require emergency surgery. Case reports and small series have established the entity of nonsurgical pneumoperitoneum and the corresponding indication for conservative management in selected cases. Nonsurgical pneumoperitoneum is dened by the pres-

ence of air in the peritoneal space that is detectable by roentgenogram and either is managed successfully by observation and supportive care alone or results in a nondiagnostic laparotomy (5). When abdominal pain and distention are minimal, and peritoneal signs, fever, and leukocytosis are absent, nonsurgical causes of pneumoperitoneum should be considered. The purpose of this paper is to review the causes and pathophysiologic mechanisms of nonsurgical pneumoperitoneum, identify pertinent clinical characteristics, and recommend when conservative management is indicated. Nonsurgical pneumoperitoneum can arise from a number of causes and will be classied into the following clinically and pathophysiologically relevant categories for this article: pseudopneumoperitoneum, abdominal, thoracic, gynecologic, and idiopathic.

METHODS
From the Department of Medicine and the Division of Pulmonary Medicine, Oregon Health Sciences University, Portland, OR. Copyright 2000 by Lippincott Williams & Wilkins

This article is a synthesis of information obtained from systematically reviewing the world literature on nonsurgical pneumoperitoneum. We found referenced articles by using

a MEDLINE Medical Literature Database search with Internet Grateful Med software. Except for inclusion of articles with historical relevance, the search was limited to the years 1970 through 1999. Keywords used for the MEDLINE search were pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identied 482 articles by using these keywords, and all were reviewed. An additional 1,533 articles were identied by using the keywords laparotomy, laparoscopy, and complications. These articles were selectively reviewed based on their relevance to nonsurgical pneumoperitoneum. To be included in this review, articles had to be published in English and be available through the Oregon Health Sciences University Library or had to have sufcient detail present in the abstract to provide useful information. We chose 153 articles for reference. Case reports for causes of nonsurgical pneumoperitoneum in which a prevalence of occurrence has been estimated are not included. Case reports for causes of nonsurgical pneumoperitoneum that may have required operative intervention for other reasons (for example, Boorhaves syndrome, pyosalpinx, vaginal-

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Table 1. Common causes and prevalence of nonsurgical pneumoperitoneum Etiology Abdominal Open abdominal surgery Laparoscopic cholecystectomy Chronic abdominal peritoneal dialysis CAPD with peritonitis PEG tube placement Diagnostic colonoscopy Therapeutic colonoscopy Spontaneous bacterial peritonitis Blunt abdominal trauma Thoracic Preterm neonatal conventional mechanical ventilation Preterm neonatal high-frequency jet ventilation Pneumomediastinum in mechanically ventilated neonates Post-heart transplant Prevalence Reference

60% 25% 10% to 34% 30% to 33% 21% to 25% 0.3% to 1% 3% 7% 5% 1% 3% 30% 1%

11 11 12, 13 1214 15, 16 17, 18 19 20 21 22 22 23 24

CAPD, continuous abdominal peritoneal dialysis; PEG, percutaneous endoscopic gastrostomy.

peritoneal stula, ruptured pyometra, ruptured liver abscess) are not included.

RESULTS
We developed ve categories for nonsurgical pneumoperitoneum. Each is described subsequently. Pseudopneumoperitoneum. Simulated roentgenographic appearance of free intraperitoneal air has been named pseudopneumoperitoneum. Pseudopneumoperitoneum was rst described in the 1930s and has been reviewed systematically with each progressive development in radiographic technique (6 8). Frequently cited causes for pseudopneumoperitoneum include adventitial air shadows, overdistension of hollow viscera, undulant conguration of the diaphragm causing basal lung to appear to lie in the diaphragm, gas trapped in established wounds, basal pulmonary atelectasis simulating subphrenic air, subdiaphragmatic extraperitoneal fat, and interposition of the hepatic exure of the colon between the right lobe of the liver and the diaphragm (9, 10). Essential features that aid in the discrimination of pseudopneumoperitoneum from true free air are failure to shift location when different radiographic positioning is used and failure of the radiolucency to collect in the most superior possible position (9). The clinical relevance consists of increased knowledge of this entity and consideration in differential diagnosis. Abdominal Causes of Nonsurgical Pneumoperitoneum. Several abdominal causes of nonsurgical pneumoperitoneum exist for which a prevalence of occurrence has been estimated. These include abdominal surgery, peritoneal
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dialysis, and most endoscopic gastrointestinal procedures (Table 1). Pneumoperitoneum occurs after open abdominal surgery in 60% or more of cases and is seen after laparoscopic procedures in about 25% of cases. Given the frequency with which abdominal procedures are performed, postsurgical pneumoperitoneum is by far the most frequent cause of nonsurgical pneumoperitoneum. Progressive resolution of free air is expected. Pneumoperitoneum will resolve within 2 days in two thirds of cases and within 5 days in 97% of cases when assessed by serial abdominal radiographs (25). Computed tomography is more sensitive for detecting intraperitoneal air than upright chest radiograph (26). Over 85% of patients will have free air seen on computed tomography scan at 3 days, and 50% will have detectable air at 6 days (27). Lean adults more commonly retain a greater volume of free air and may have prolonged duration of pneumoperitoneum after abdominal procedures than overweight adults (28). A clinical course marked by peritoneal signs on physical examination and increasing volume of pneumoperitoneum suggests intraabdominal pathology that may necessitate operative management. Abdominal peritoneal dialysis is another frequently cited procedural cause of nonsurgical pneumoperitoneum (Table 1). It occurs with catheter placement in 11% to 34% of cases, and resolution occurs within 27 days. Of those with pneumoperitoneum, a small percentage, 6% to 14%, will have documented iatrogenic visceral perforations, usually with accompanying signs of peritonitis. Ten to thirty-three percent of chronic ambulatory

peritoneal dialysis patients may have asymptomatic pneumoperitoneum, most likely related to technical competence of performing exchanges. Chronic ambulatory peritoneal dialysis patients with secondary bacterial peritonitis may also have pneumoperitoneum detectable on radiograph in up to one third of cases. Most endoscopic gastrointestinal procedures also have been associated with the development of nonsurgical pneumoperitoneum. The occurrence of pneumoperitoneum after percutaneous endoscopic gastrostomy is approximately 25% (Table 1). Radiographic resolution usually occurs within 1 wk (15, 16). Pneumoperitoneum in this setting may be related to high intragastric air pressure by endoscopic air insufation in conjunction with microscopic perforation of the abdominal wall and gastric parenchyma. Clinical correlation and vigilance for abdominal pain and distention, peritoneal signs, fever, and leukocytosis should guide management and need for surgical evaluation. Nonsurgical pneumoperitoneum occasionally occurs after diagnostic or therapeutic colonoscopy (Table 1). Although pneumoperitoneum after colonoscopy initially was thought to necessitate surgical exploration, conservative management is warranted in most cases, even if minor peritoneal signs are present (29, 30). Postpolypectomy syndrome is a novel phenomenon that has been described with transmural burns of the colon after endoscopic polypectomy and may manifest rarely as pneumoperitoneum (17, 31). The syndrome typically presents with fever, abdominal pain, and peritoneal signs. The clinical signicance has not been elucidated fully, but case reports suggest that conservative therapy with observation and antibiotics may be appropriate to avoid unnecessary surgery. Two mechanisms have been proposed for the development of pneumoperitoneum after colonoscopy. One suggests that microperforation and dissection of air occur through lymphatic or submucosal channels that eventually pass to the peritoneum. An alternative mechanism suggests that air extravasates through thinned, although intact, bowel wall without demonstrable or clinically significant perforation (5). For nonsurgical pneumoperitoneum to develop by this mechanism and resolve with conservative management, the leak must be small enough to permit the escape of gas without extravasation of bowel contents and
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must occur in a patient with adequate resistance to infection. Numerous case reports exist for less common causes of nonsurgical pneumoperitoneum of abdominal etiology (Tables 2 and 3). Pneumatosis cystoides intestinalis (PCI), also referred to as cystic lymphomatosis or enteromesenteric emphysema, is the most common abdominal cause of nonsurgical pneumoperitoneum that is not procedure related. PCI is characterized by multiple intramural gaslled cysts in any portion of the gastrointestinal tract but is most commonly found at the terminal ileum. Rupture of these submucosal and subserosal cysts causes pneumoperitoneum. PCI usually is found in conjunction with other primary diseases, including collagen vascular diseases, bone marrow transplantation, malignancy, inammatory bowel disease, acquired immunodeciency syndrome, and others (Table 2). A number of case reports also have no identiable cause. The condition is generally nonsurgical and asymptomatic, although nonspecic complaints such as vomiting, diffuse abdominal pain, diarrhea, abdominal distension, and tenesmus are seen in some cases (54). Pneumatosis cystoides intestinalis generally resolves spontaneously, although recurrence is well documented. Treatment with hyperbaric oxygen and antibiotics has demonstrated some efcacy, but conservative and watchful management is generally sufcient. Complications of PCI, including hemorrhage, obstruction, volvulus, perforation, sepsis, and ischemic bowel occur in approximately 3% of cases (121). Our review found 55 reported cases of PCI, of which 9 (16.4%) underwent surgical exploration. Thoracic Causes of Nonsurgical Pneumoperitoneum. Unlike abdominal causes of nonsurgical pneumoperitoneum, few thoracic causes exist for which a prevalence of occurrence has been estimated. In the pediatric population, nonsurgical pneumoperitoneum occurs in 1% to 3% of mechanically ventilated preterm infants, depending on the mode of ventilation (Table 1). If a neonate develops pneumomediastinum while receiving mechanical ventilation, the risk of nonsurgical pneumoperitoneum is approximately ten-fold higher. The most frequently cited thoracic causes of nonsurgical pneumoperitoneum in the adult literature are mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax (Table 3). Although adults
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Table 2. Causes of pneumatosis cystoides intestinalis Surgical Intervention 0 0 2 1 0 0 1 0 1 0 0 0 1 0 3

Cause Bone marrow transplant Chemotherapy Scleroderma Lupus Dermatomyositis Nontropical sprue Diverticular disease Small bowel resection Intestinal pseudoobstruction Jejunal-ileal bypass Gastric outlet obstruction Sclerotherapy AIDS Heart transplant Idiopathic

No. Cases 10 1 10 2 1 1 3 2 2 1 1 1 6 1 13

References 32, 33 3437 5, 3843 44, 45 46 47 5, 48, 49 50 3437 51 52 53 54 55 54, 56, 57

AIDS, acquired immunodeciency syndrome. Table 3. Specic causes of nonsurgical pneumoperitoneum Surgical Intervention

Cause Thoracic Mechanical ventilation Cardiopulmonary resuscitation Pneumothorax Tracheal rupture Median sternotomy Blast injury Abdominal Barium enema with rectal insufation Splenic embolization Pancreatic transplant Gastric emphysema Gynecological Pelvic manipulation or insufation Ovarian cancer

No. Cases

References

40 21 16 4 2 1 2 2 1 1 14 1

12 6 2 2 0 1 0 0 0 0 1 1

5, 52, 5883 3, 8489 9095 3, 62, 9698 99 100 101, 102 103 104 105 106119 120

receiving prolonged mechanical ventilation are at risk for developing nonsurgical pneumoperitoneum, no data are available to estimate the prevalence. Risk factors include high airway pressures, large tidal volumes, noncompliant lungs, and preexisting pulmonary disease, including obstructive airway disease and acute respiratory distress syndrome. Many different causes of pneumothorax, including catamenial, lymphangiolieomyomatosis, postprocedure (thoracentesis, chest tube thoracostomy, bronchoscopy), and therapeutic pneumothorax for tuberculosis, have been associated with nonsurgical pneumoperitoneum. Our review found 85 reported cases of nonsurgical pneumoperitoneum from thoracic causes, of which 23 (27%) underwent surgical exploration. Management strategies for pneumoperitoneum of suspected thoracic etiology can be conservative when peritoneal

signs are absent, history does not include a ruptured viscus, and clinical suspicion for a ruptured viscus is low. Perforation can be excluded by radiographic imaging with water-soluble contrast material administered via oral, rectal, or enterostomy tube (122, 123). Of note, tension pneumoperitoneum has been described, in which surgical decompression was necessary, even in the absence of peritoneal signs, to relieve vascular collapse (87, 124). Several authors have investigated the relationship between mechanical ventilation and pneumoperitoneum. A direct correlation between increased airway pressures and barotrauma has been demonstrated. Animal models receiving intratracheal pressures 40 cm H2O routinely develop interstitial emphysema (125). When pressures are 50 cm H2O, pneumomediastinum occurs, and at pressures 60 cm H2O, subcutaneous emphysema
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Table 4. Miscellaneous causes of nonsurgical pneumoperitoneum

e suggest that when abdominal pain and

Cause Cocaine use Scleroderma without PCI Diving with decompression Dental extraction Idiopathic No. Cases 2 9 4 1 20

Surgical Intervention 0 1 0 0 10

References 139, 140 43, 141144 145148 149 5, 70, 83, 150153

distension are minimal, and peritoneal signs, fever, and leukocytosis are absent, nonsurgical causes of pneumoperitoneum should be considered for subsequent conservative management.

PCI, pneumatosis cystoides intestinalis.

The British pediatric literature suggests that analysis of the partial pressure of oxygen in intraperitoneal free air may aid in documenting a thoracic source of pneumoperitoneum (136, 137). The alveolar partial pressure of oxygen may be calculated as follows: PaO2 (PB Pwater) FIO2 PaCO2/R

and pneumoperitoneum are observed. Human data suggests similar pressure thresholds: Hillman reviewed 28 cases of pneumoperitoneum caused by mechanical ventilation and found that most peak inspiratory pressures exceeded 40 cm H2O, and positive end-expiratory pressures exceeded 6 cm H2O (126). Two competing mechanisms for the passage of air from thoracic to abdominal cavities have been proposed: a) the direct passage through pleural and diaphragmatic defects (2, 62, 87, 127, 128), and b) the classically described passage via the mediastinum along perivascular connective tissue or major diaphragmatic portals to the retroperitoneum and nally to the peritoneum (45, 70, 129, 130). Macklin and colleagues (131, 132) studied the transport of air along vascular sheaths from the alveoli to the mediastinum, and then to the retroperitoneum and peritoneum in the original mechanistic description of pneumoperitoneum of thoracic etiology. Subsequent case reports provided examples where no evidence could be found for pneumomediastinum or where evidence contrary to the classic pathway existed (21, 62, 129, 133). These and other case reports suggest that microperforations might exist in the diaphragm that parallel pillars of the diaphragm, may be increased in areas of demonstrated weakness such as posterolateral and parasternal regions that correlate with hernias of Bochdalek and Morgagni, respectively, or simply may represent natural microscopic passageways analogous to the proposed mechanism of cirrhotic uid traversing the diaphragm (134, 135).
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where PB is the barometric pressure, Pwater is the partial pressure of water vapor, FIO2 is the inspired oxygen content, PaCO2 is the alveolar CO2 partial pressure, and R is the respiratory quotient. The PaO2 then may be compared to that measured in the peritoneum, and agreement between the two generally suggests a thoracic source in patients with an appropriate clinical history. The operating characteristics of this test are not known, and no clinical trials have evaluated positive or negative predictive values for this test.

Gynecologic Etiologies
Gynecologic causes of nonsurgical pneumoperitoneum, although rare in comparison with other etiologies, occur when air passes upward through the genital tract to the peritoneum via the uterus and fallopian tubes. The introduction of air through the genital canal can occur either by pressure applied externally or by a vacuum created by rapid positional changes of the lower torso. Specic examples include vaginal insufation by orogenital sex (106, 110, 119), vaginal douching (110, 111, 118), postpartum knee-chest exercises (107, 113), use of bulb aspiration in pelvic exam (108), tubal insufation in hysterosalpingogram (114), pelvic inammatory disease (114), and coitus (109, 116, 117). Most reports suggest that genital anatomical abnormalities by surgery or parturition predispose to pneumoperitoneum of gynecologic etiology, although other reports suggest this is not necessary. Pregnancy may be a risk factor for pneumoperito-

neum and may pose particular danger, because vaginal insufation has been attributed to death by air embolization in this circumstance (112, 138). Management again is conservative, and priority is given to history in the consideration of this nonsurgical cause of pneumoperitoneum in female patients. Our review found 15 reported cases of nonsurgical pneumoperitoneum from gynecologic causes, of which 2 (13.3%) underwent surgical exploration. Miscellaneous and Idiopathic Causes of Nonsurgical Pneumoperitoneum. Miscellaneous causes of nonsurgical pneumoperitoneum are listed in Table 4. In addition, at least 20 cases have been published for which no clear etiology of pneumoperitoneum was established. This suggests the possibility of subclinical visceral perforations that resolve with or without surgical intervention, or other as-yet unidentied processes. Our review found 36 miscellaneous or idiopathic cases of nonsurgical pneumoperitoneum, of which 11 (30.6%) underwent surgical exploration. In summary, pseudopneumoperitoneum and four categories of nonsurgical pneumoperitoneum have been reviewed: abdominal, thoracic, gynecologic, and idiopathic. Excluding causes for which a prevalence of occurrence has been estimated (Table 1), we found 196 reported cases of nonsurgical pneumoperitoneum, of which 45 underwent surgical exploration without evidence of perforated viscus. Many cases occurred as a result of a procedure or as a complication of medical intervention. Most episodes of nonsurgical pneumoperitoneum have historical or diagnostic clues that suggest the observational approach. A prospective trial has not been performed, making it difcult to establish rm guidelines for the conservative management of pneumoperitoneum. However, on the basis of the reported studies, we suggest that when abdominal pain and distension are mini2641

mal, and peritoneal signs, fever, and leukocytosis are absent, nonsurgical causes of pneumoperitoneum should be considered for subsequent conservative management. By acquiring a working knowledge of the wide array of potential causes of pneumoperitoneum and their mechanisms, unnecessary surgical exploration and its associated morbidity frequently may be avoided.

17.

18.

19.

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