Non‐surgical pneumoperitoneum associated with mechanical ventilation

Abstract

Dear Editor, Non-surgical pneumoperitoneum from an intrathoracic route is the most frequently reported cause in non-surgical perito-neal air collection. 1,2 The true incidence of pneumoperito-neum associated with mechanical ventilation is unknown, but current estimates range from rare to 7% of intubated patients in the intensive care unit. This complication may lead to unnecessary laparotomy, however, if correctly diag-nosed, it can be observed successfully without surgical inter-vention. We experienced a patient with subcutaneous emphysema, mediastinal emphysema, and pneumoperito-neum in whom coughing may have had a causative role, which was recognized and was managed without laparotomy. A 40-year-old female was transferred to our hospital due to loss of consciousness following a suicide attempt (hanging) and an overdose of anti-anxiety medicine. Although her vital signs were stable at admission, the patient was intubated, sedated, and ventilated in the intensive care unit, as her Glasgow Coma Scale score was 3 (E1, V1, and M1). Assisted ventilation was used with a fractional inspired oxygen concentration (FiO2) of 0.4 and a positive airway pressure of 5 cm H2O or less. On the second day of admis-sion, she was alert with strong spontaneous breathing on the ventilator. Routine chest and abdominal X-ray revealed pneumothorax and pneumoperitoneum. Computed tomogra-phy scan of the chest and abdomen confirmed the presence of free intraperitoneal air without free fluid (Fig. 1). The patient was not symptomatic and had no fever or dyspnea. The abdomen was soft and flat without guarding or disten-sion. Leukocytosis was present, with a white cell count of Fig. 1. Images of computed tomogra-phy scans on day (d) 1 (on admission), 2, and 5 of a 40-year-old female who was intubated, sedated, and ventilated in the intensive care unit following a suicide attempt (hanging) and an over-dose of anti-anxiety medicine. Although free air was not seen on day 1, com-puted tomography scan of the chest and abdomen confirmed the presence of free intraperitoneal air without free fluid under the diaphragm (arrows). Left chest tube was inserted on day 2. Pneu-moperitoneum was almost cleared with conservative management.