Case Presentation: An 87-year-old Caucasian male with a history of benign prostatic hyperplasia presented to the hospital with urinary incontinence, abdominal discomfort, and altered mentation. The patient required hospitalization for worsening symptoms. On admission, he was hypotensive (BP of 88/55 mmHg), tachycardiac (143 b/min), respiratory rate of 20 bpm, and temperature of 96.3° F. Pertinent exam findings included an enlarged prostate and abdominal distension with an otherwise normal examination. A Computerized tomography(CT) scan abdomen & pelvis, reported bilateral hydronephrosis with an enlarged prostate. Initial laboratory evaluation revealed serum creatinine of 12 mg/dL, anion metabolic acidosis with lactic acidosis. Urine analysis was positive for signs of infection. The patient was diagnosed with sepsis secondary to urinary tract infection, requiring intravenous antibiotics, fluid resuscitation, and ICU admission. Blood and urinary cultures were positive for E. coli.
On the 5th day of admission, patient experienced increased abdominal pain and subjective fever. He was vitally stable. Abdominal exam was significant for hypoactive bowel sounds, mild distension, guarding, tympanic to percussion, and diffuse abdominal tenderness. An upright chest and abdominal radiograph revealed free intraperitoneal air and nonobstructive bowel gas pattern. A chest x-ray is taken three days prior, which revealed no acute findings. The surgical team was emergently consulted, with resultant exploratory laparoscopy, and ultimately laparotomy for pneumoperitoneum. Surgical exploration of the abdominal cavity revealed no perforation. Post-operative x-ray demonstrated resolution of the pneumoperitoneum.
Discussion: Pneumoperitoneum, often a surgical catastrophe describes the presence of free air in the peritoneal cavity. About 90% of reported cases have surgical etiology. However, 10% of cases are related to non-surgical pneumoperitoneum. There are various causes of non-surgical pneumoperitoneum. Sepsis secondary to gas-forming bacteria has rarely been reported in the literature. Sepsis may induce intestinal micro perforation related to increased inflammatory mediators. In our case, the patient developed pneumoperitoneum despite appropriate treatment with sensitive antibiotics and absence of intra-abdominal pus.
Chandler et al. reported that 28% of patients with nonsurgical spontaneous pneumoperitoneum were subjected to surgical exploration. They report three recurring themes amongst these patients: the decision to perform exploratory surgery completely based on radiological evidence, radiolucency consistent with pneumoperitoneum was not located at the apex of the diaphragm, and the presentation of marginal peritonitis symptoms. Early recognition of nonsurgical spontaneous pneumoperitoneum is important in preventing unnecessary surgical procedures that expose patients to complications and extended recovery periods. More insights into etiopathogenesis will lead to improved case fatality and patient outcomes.
Conclusions: In non-surgical pneumoperitoneum, conservative treatment may be appropriate, preventing unnecessary surgical intervention. Gram-negative sepsis represents a rare cause of pneumoperitoneum and should be recognized early to prevent unnecessary intervention. Clinicians should familiarize with this rare clinical entity to improve case related morbidity and mortality.