Diagnosis and management challenges of spontaneous pneumoperitoneum associated with infectious pneumonia: case report and literature review

Introduction and importance

Spontaneous pneumoperitoneum is rare and can be treated without surgery. There are no clear criteria for determining which patient with pneumoperitoneum does not require surgery. We present a patient admitted to our centre for the management of infectious pneumonitis associated with spontaneous pneumoperitoneum.

Presentation of case

A 76-year-old white male was admitted with dyspnoea, cough and diarrhoea for three days. The patient had heart rate of 117 beats per minute, oxygen saturation of 84 % and Glasgow scale of 13/15. Pulmonary embolism was suspected. The chest CT scan showed interstitial syndrome, bronchial dilatation, emphysema and pneumoperitoneum. He was assessed by the surgical team. The abdomen was distended with tympanism and bowel sounds present. An exploratory laparotomy was proposed, but the patient refused with an improvement in his state two days later. We suspected that the patient had a sealed perforation. An abdominal CT showed pneumoperitoneum with no signs of hollow organ perforation. We concluded to spontaneous peritoneum.

Clinical discussion

Spontaneous pneumoperitoneum has many causes dominated by mechanical ventilation and recently COVID-19 infection. It remains poorly understood, this limits the development of a decision-making algorithm. It must be differentiated from hollow organ perforation, which has a high mortality rate. This requires careful clinical evaluation, monitoring of the disease progression and thorough analysis of the abdominal CT scan.

Conclusion

Spontaneous pneumoperitoneum is poorly understood and its causes are numerous. Deciding on conservative treatment requires rigorous clinical analysis. Despite advances in medical imaging, surgery is the best option in cases of doubt.