Spontaneous Pneumoperitoneum Following Blunt Trauma Chest - Diagnostic Dilemma - Role of Diagnostic Laparoscope - a Case Report (original) (raw)
Related papers
Trauma & Treatment, 2013
Introduction: Pneumoperitoneum is a striking feature of hollow viscous perforation and may need of immediate surgical intervention. Blunt trauma chest with pneumoperitoneum without evidence of hollow viscous perforation is unusual and the condition is called spotaneous pneumoperitoneum. Case Presentation: A 29 year male presented to the emergency department after a road traffic accident with hypotension and respiratory distress. Clinically there was surgical emphysema associated with diminished breath sound over left half of the chest and multiple contusions over left hypochondrium and left flank. Bedside X-ray showed fracture of ribs on left side with pneumothorax and air under both the dome of diaphragm. Emergency tube thoracostomy done and respiratory symptoms improved. Further patient evaluated with Ultrasound abdomen and Computerized tomogram of abdomen. Dilated bowels, gross pneumoperitoneum with minimal fluid collection was noted. Diagnostic laparoscopy done to find out hollow viscous perforation or diaphragm injury but to the surprising hollow viscous and diaphragm found to be normal. Case Discussion: Pneumothorax and pnemoperitoneum with presence of abdominal contusions make the surgeon in dilemma for choosing conservative or therapeutic approach. Conclusion: Diagnostic laparoscopy with systemic exploration of abdominal organs and spaces will help in diagnosis and mandatory laparotomy may avoided.
Pneumothorax and concomittant idiopathic pneumoperitoneum - at blunt thoracic trauma. Case Reporting
2019
Shqiptar Demaçi*, Bedri Osmani, Fitim Selimi, Saudin Maliqi, Yllka Krasniqi ( Thoracic Surgery Clinic , University Clinical Center of Kosova-Prishtina; UBT – University for Business and Technology- Kosova ) Pneumothorax and idiopathic concomittant pneumoperitoneum - at blunt thoracic trauma. Case report Abstract: The presence of concomitant pneumoperitoneum in a severed corporal injury (head, neck / thorax / abdomen) with more pronounced thoracic injury is extremely rare and the exact mechanism of its presentation is unknown (idiopathic). The dilemma lies in deciding whether or not to have surgical treatment. The case of a 31-year-old injured person who accidentally falls off the stairs and falls downstairs (2.5 - 3 meter height) on a grate-reinforced base and being treated after all clinical and imaging tests, and careful observation a week is only done in a conservative (non-surgical) way, bed regimen and empirical therapy: antibiotics and analgesics. Literature is consulted and suggestions are given. Keywords: blunt chest trauma, pneumothorax; idiopathic pneumoperitoneum; *Corresponding author: Shqiptar Demaçi, email: shdemaci@hotmail.com; University Clinical Center of Kosova-Prishtina; UBT – University for Business and Technology- Kosova Introduction: Pneumoperitoneum (PP) is a radiological finding that is indicative of severe abdominal disease. 90% of PP cases result from perforated organs demonstrated as free intraperitoneal air on radiography. [1] Pneumoperitoneum is caused as air enters through the abdominal wall, diaphragmatic wall or retroperitoneum. [2] Pneumoperitoneum caused by blunt trauma usually indicates the need for emergency laparotomy. However in 5 ~ 15% of cases with pneumoperitoneum no surgical management is required, because the air comes from sources other than the cavity organs. [3] The other type of idiopathic PP, which is much rarer, is that associated with pneumothorax secondary to trauma. [4-9] In these cases, air from the thorax enters through the rupture of the lungs and finds the dissection inserted into the retroperitoneum or inserted directly through the diaphragm defect [10] Diagnosing PP in this group of patients does not necessarily mean that there is true gastrointestinal perforation therefore surgery is not always required. Conservative treatment and careful observation can avoid unnecessary surgery in these patients. [11] Case report The injured, male 31 years old, is admitted to the Thoracic Surgery Clinic - UCCK Prishtina, to be treated for injuries received as a result of slipping while walking up the stairs and falling from the first floor to a reinforced concrete base (reinforcement) ). There is pain in the head, right side-chest, accompanied by difficulty breathing and abdominal pain. Laboratories: hematocrit 0.47; easily elevated aspartate amino transferase (AST): 96 U / L (reference values for males 10-40 U / L); Imaging: CT of the natural chest / abdomen (no contrast) on the day of injury shows minimal right anterior-apical pneumothorax (fig.1), basal pulmonary contusions-right side; pleural effusion-right side. The pneumomediastinum-right side is also seen (fig 2). Thoracic drainage is done on the right side, from where air and blood -100 ml are drained . The abdominal organs are without traumatic changes; subcutaneous emphysema along the left abdominal oblique muscle; Two days later CT of the abdomen / pelvis shows significant amounts of free intraabdominal air (intra and retroperitoneal) (Fig.3) - pneumoperitoneum and in some CT scans of the thorax hemopneumothorax is seen on the right side with the presence of drainage on the right side. Two days after trauma, the abdominal surgeon finds slight tenderness in the epigastric region. On native chest / abdomen radiographs (fig.4) there is transparency (air) under the diaphragmatic domes. Six days after injury the air persists under the diaphragmatic domes but this does not correspond to the stable clinical condition of the patient. There is no abdominal pain. One week after the injury, the esophagus and gastroduodenum are passed with hydrosoluble contrast per os and it is found: normal esophageal passage; no radiological signs are observed for hiatal hernia nor for diaphragmatic rupture . Fig.1. CT thorax/ Pneumothorax –r ight side Fig. 2. Pneumomediastinum (billateraly) Fig.3.Pneumoperitoneum on CT scann ( sagittal plan) Fig.4.Pneumoperitoneum on native X-ray of chest(thoracic drain in situ)and abdomen Discussion To date, no definitive explanation has been given for the presence of Pneumothorax or pneumomedistinum associated with pneumoperitoneum (PP). The association between pneumothorax and idiopathic PP has been reported in several case-study studies in patients who have suffered blunt trauma. [4-9] Based on some reliable experimental studies, it has been said that interstitial emphysema develops when the intratracheal pressure exceeds 40 cm of the water column, pneumomediastinum develops in 50 cm of the water column, pneumoperitoneum may appear when the pressure exceeds 60 cm of the water column. [12] As a hypothetical model, the increased intrathoracic air pressure dissects the planes / fascial layers close to the mediastinum. Air can then dissect through various spaces including the pleura and along the esophagus and large thoracic vessels to the retroperitoneum, from where it can then rupture into the peritoneal cavity. [13] Hefny et al. (14) (2014) showed that free intraperitoneal air found on CT in patients with blunt abdominal trauma (21 cases) is an unsafe radiological finding for intestinal perforation and the decision for laparotomy should be based on combined clinical and radiological findings. They suggest for active observation with conservative management that may avoid unnecessary laparotomy. Since the study is retrospective with a small number of cases - the conclusion can not be reached. In the clinical case evaluated by us, there is association of PP with pneumothorax with small amount of blood in the right chest and small amount of pneumomediastinum. Since there is no general clinical surgical detachment nor from the abdominal or thoracic side, its treatment is done conservatively. Conclusion: In cases with associated PP, in blunt injuries of the body or chest / abdomen, the clinical condition should be carefully evaluated in accordance with the CT imaging findings and, depending on them, conservative or surgical treatment should be performed. Literature: 1. McGlone FB, Vivion CG Jr. Spontaneous pneumoperitoneum. Gastroenterology. 1966;51:393-398) 2. Di Saverio S, Filicori F, Kawamukai K,Boaron M,Tugnoli G. Combined pneumothorax and pneumoperitoneum following blunt trauma: an insidious diagnostic and therapeutic dilemma. Postgrad Med J 2011;87:75–8, http://dx.doi.org/10.1136/pgmj.2010.110262) 3. Mularski RA, Sippel JM, Osborne ML. Pneumoperitoneum: a review of nonsurgical causes. Crit Care Med 2000;28:2638-44. 4. Glauser FL, Bartlett RH. Pneumoperitoneum in association with pneumothorax. Chest. 1974;66:536-540]; 5. Andrew TA, Milne DD. Pneumoperitoneum associated with pneumothorax or pneumopericardium: a surgical dilemma in the injured patient. Injury. 1979;11:65-70]; 6. Hashmi S, Rogers SO. Tension pneumothorax with pneumopericardium. J Trauma. 2003;54:1254. 7. Gardner-Thorpe D, Maddox PR. Idiopathic pneumoperitoneum following blunt chest trauma: a case report. Injury. 1999;30:511-513. 8. Hamilton P, Rizoli S, McLellan B, et al. Significance of intraabdominal extraluminal air detected by CT scan in blunt abdominal trauma. J Trauma. 1995;39:331-333. 9. Krausz M, Manny J. Pneumoperitoneum associated with pneumothorax: a surgical dilemma in the posttraumatic patient. J Trauma. 1977;17:238-240. 10. Ferrera PC, Chan L. Tension pneumoperitoneum caused by blunt trauma. Am J Emerg Med. 1999;17:351-353. 11. Ilya Sabsovich; Ravi Desai, Rafael Alba, Jose Yunen, David Sammett. Idiopathic pneumoperitoneum after blunt chest trauma; May 09, 2008. MD Magazine Resources 12. Grosfeld J.L., Boger D., Clatworthy H.W., Jr. Hemodynamic and manometric observations in experimental air-block syndrome. J Pediatr Surg. 1971;6:339–344; 13. Assenza M., Passafiume F., Valesini L., Centonze L., Romeo V., Modin C. Pneumomediastinum and pneumoperitoneum after blunt chest trauma: the Macklin effect. J Trauma Treat. 2012;1(1):1–5. 14. Hefny A.F., Kunhivalappil F.T., Matev N., Avila N.A., Bashir M.O., Abu-Zidan F.M. Usefulness of free intraperitoneal air detected by CT scan in diagnosing bowel perforation in blunt trauma: experience from a community-based hospital. Injury. 2014;(September 16) pii:S0020-1383(14)00431-8
Pneumoperitoneum due to pneumothorax in blunt thoracoabdominal trauma: A diagnostic challenge
Journal of Emergency Practice and Trauma, 2021
Objective: A Perforation of hollow viscus is the most common cause of pneumoperitoneum after a blunt thoracoabdominal trauma and demands prompt surgical exploration. Alternative routes into the peritoneal cavity, such as the presence of a diaphragmatic laceration associated with pneumothorax, although rare, should be considered when approaching these patients. Case Presentation: We present the case of a 78-year-old male admitted to the emergency department after being ran over by a car resulting in right thoracoabdominal trauma, presenting with dyspnea and signs of peritoneal irritation. CT scan identified right pneumothorax, pneumoperitoneum and free abdominal fluid. The pneumothorax was drained and posteriorly he underwent exploratory laparotomy where a traumatic laceration of the diaphragm was identified as the cause of pneumoperitoneum. Conclusion: Alternative causes of pneumoperitoneum should be considered in blunt thoracoabdominal trauma with possibility of conservative manage...
Pneumoperitoneum in a patient with pneumothorax and blunt neck trauma
International Journal of Surgery Case Reports, 2014
INTRODUCTION: Blunt trauma as a cause of pneumoperitoneum is less frequent and its occurrence without a ruptured viscus is rarely seen. PRESENTATION OF CASE: We report a case of blunt neck trauma in which a motorcycle rider hit a fixed object causing severe laryngotracheal injury. The patient developed pneumothorax bilaterally and had pneumoperitoneum despite no injury to the internal viscus. Bilateral chest tube drainage and abdominal exploratory laparotomy was performed. CONCLUSION: Free air in the abdomen after blunt traumatic neck injury is very rare. If pneumoperitoneum is suspected in the presence of pneumothorax, exploratory laparotomy should be performed to rule out intraabdominal injury. As, there is no consensus for this plan yet, further prospective studies are warrant. Conservative management for pneumoperitoneum in the absence of viscus perforation is still a safe option in carefully selected cases.
Kathmandu University medical journal, 2017
Pneumoperitoneum is mostly caused by visceral perforation and surgical intervention; however non-surgical pneumoperitoneum has been reported without evidence of visceral disease. Blunt chest trauma causing an abrupt rise in thoracic pressure can leak air through the microscopic diaphragmatic defects or the mediastinum along perivascular connective tissue and cause pneumoperitoneum. We hereby present a case of non-surgical pneumoperitoneum after blunt chest trauma that was brought to the emergency department of college of medical sciences teaching hospital with features of bilateral pneumothorax with subcutaneous emphysema and abdominal distension which was diagnosed and managed promptly with bilateral chest drain and other supportive treatments.
Perforation of intrathoracic colon causing acute pneumothorax
Thorax, 1983
Traumatic diaphragmatic hernias, although not uncommon, present infrequently enough to cause diagnostic difficulty, particularly in the acute phase. Blunt injuries account for more diaphragmatic ruptures than direct trauma and the ruptures are usually left sided. The case presented here is reported because of its dramatic manifestation, several years after the initial injury.
Post-Traumatic Pneumoperitoneum Due to High Compression Trauma -A Case Report
Pneumoperitoneum and perforation are the most commonly seen complications in cases of rectal air entry at a high velocity in a short duration of time. We present a case of 20 year old male who was brought to emergency department with severe abdominal pain and distension for 2 hours. On asking history he told a friend of him pumped high-pressure air from an air compressor into his anus while he was working in a factory. The examination and investigations of patients were suggestive of free gas in peritoneal cavity (pneumoperitoneum) and the patient was taken for emergency exploratory laparotomy. On exploration, gaseous distention of whole colon was observed with multiple serosal tear along the colon. A defect of 2x2 cm seen in middle of transverse colon at anti mesenteric border. The defect was closed primarily.