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Postoperative spontaneous pneumoperitoneum
POSTOPERATIVE
SPONTANEOUS JOHN J. CUNNINGHAM,
PNEUMOPERITONEUM M.D.
Chief of the SurgicaI Staff, Our Lady of Lourdes Hospital BINGHAMTON,
T
HE presence of air in the peritoneal cavity is to be expected in any condition in which excess of air is alIowed by injury or perforation of the intestina1 tract or when the peritoneum is opened as in surgica1 or traumatic conditions. Under modern conditions, this has aIso been used in the Rubin test and in peritoneoscopy as we11 as in the introduction of air or other gases for therapeutic or diagnostic reasons. Aside from the symptoms due to the immediate introduction of the air with its accompanying changes in pressure, this is unimportant as the air is absorbed within a comparatively short space of time. The presence of air”is aJso found in peritonitis due to gas forming organisms. Gas or air in the peritonea1 cavity without demonstrabJe reason and in sufficient amounts to cause symptoms is rare. This condition, caIIed “ spontaneous pneumoperitoneum,” has been recorded five times previousIy according to the Iiterature avaiIabIe to the writer. HinkeIl summed up the Iiterature to date in an admirabIe paper and aIso gave in detail the known etioIogy and pathoIogy of the condition. He states : “The intra-abdomina1 pressure is nearIy aIways negative (Wagoner) and, according to SaIkin, it may reach 50 mm. of water beIow that of the atmosphere. The introduction of fluid or air into the peritoneal cavity does not raise the pressure sharpIy because of the ‘abdomina1 accommodation’ described by Coombs. Therefore, if air shouId enter through an aperture in the diaphragm, one could not expect it to be expeIIed through the same route unIess the intra-abdomina1 pressure became greater than that of the atmosphere.” Thus, the presence of air due to perforations of the intestina1 tract or from
NEW YORK
openings to the atmosphere, would be in sufficient amounts to equalize the pressure between the peritoneum and the externa1 source and wouJd not be progressive. According to this idea, the presence of a distention which was sufficient to cause symptoms and progressive enough in nature wouId almost have to be connected in some way with the bronchia tree, barring gasforming organisms or repeated perforations. The mechanism invoIved would be essentiaIIy the same as that in tension pneumothorax, the Iungs being the only pump-Iike mechanism sufficient to produce the extreme pressure deveIoped in the peritonea1 We assume this condition was cavity. caused by a tear through the diaphragm into the bronchia tree, pIus a baII-valve mehanism of the diaphragm. The foIIowing case of spontaneous pneumoperitoneum is the first of its kind to be reported in a patient foIIowing a surgica1 procedure in which the symptoms were so aIarming as to constitute a serious factor in an otherwise norma convaIescence. It corresponds with four of the five cases previousIy reported, in that there was an accompanying chest condition which couId be expIained on the basis of the mechanism noted above (HinkeI). The fifth recorded RigJer,2 was the onIy one in which the symptoms were due to some intestina1 condition. Since perforation of the intestina1 tract with the appearance of air is common and since these are often found onIy at autopsy or at operation, this case (Rigler) whiIe undoubtedIy spontaneous pneumoperitoneum, might very we11 have been due to some perforation. In his patient aIso the symptoms were not progressive and the presence of air was not in sufficient amount to cause serious symptoms.
725
726
FIG.
A merican Journal Of Surgery
I. X-ray
showing Iection
CASE
Cunningham-Pneumoperitoneum
subdiaphragmatic of air.
col-
REPORT
CASE I. D. Y., aged fifty-one, was admitted to Our Lady of Lourdes Hospital because of biIatera1 inguina1 hernias of thirty years’ duration. The patient has been weI1, aside from influenza in 1918 of three weeks’ duration which was folIowed by a chronic bronchitis with attacks of what was diagnosed as bronchial asthma at infrequent intervaIs. There was no history of intestina1 disturbances; his boweIs were regular; he ate everything and used tobacco and alcohol moderateIy. He had always been an out-of-doors man and the only reason he was being operated upon was that he noted that he tired more easiIy especially when he was out hunting or fishing. At operation, done under spina anesthesia, the hernias were repaired by the Bassini technic without diff&Ity. The patient’s condition was good through the procedure and he was returned to his room in exceIIent condition. fluids were aIlowed immediateIy after operation and peniciIIin was started at once. The bowels moved with an enema on the third postoperative day and the patient was eating weI1. ConvaIescence was uneventfu1 unti1 on the fifth postoperative day, when foIIowing an enema, the patient complained of moderate abdominal pain and a sIight chill. His temperature rose t0 IOZOF. ; the abdomen became distended but not aIarmingIy so. He did not vomit and was not nauseated. At this time the wounds were healed and his temperature had been norma for two days. He aIso compIained
JUNB.19.47
of a certain amount of chest distress and had a severe coughing spell. The following day the distention was much more pronounced; however, he \vas taking Iiquids we11 and he stated that he felt fine. An enema was given and returned with a moderate amount of gas and some liquid stoo1; the distention, however, remained constant. His condition remained the same until the next day when the distention was so severe as to cause respiratory embarrassment. He was pIaced in an oxygen tent, but there was no improvement. During this entire period he had no complaints aside from a feeIing of distention. He had no more coughing spells; he was taking Iiquids we11 and enemas were returned with what was considered fair results. The distention, however, reached the point where the abdomen was aImost boardlike to the touch; there was a tympanitic note on percussion. X-ray examination reveaIed the picture seen in Figure I. A diagnosis of pneumo-peritoneum of unknown origin was made and under I per cent novocanine a needIe was inserted into the peritoneum at the Ieft upper quadrant and 3,000 cc. of air was removed with immediate relief. Air was under such pressure as to force the gIass pIunger out of a dry IOO cc. syringe. Suction was not necessary at any time during the procedure. The foIlowing morning the distention had increased from what it had been immediately after the tapping but not to a comparable degree with that seen before. He was again tapped with a trocar and an unmeasured amount of air was withdrawn. A positive pressure was purposely left in order to prevent possibIe vascular symptoms due to the sudden intra-abdominalIy change. Further tappings were not used and the abdomen over a period of ten days graduaIIy became softer unti1 at the time of discharge it was practicaIIy normaI. At no time other than the initia1 insuIt was there an elevation in temperature. The patient sat on the edge of the bed on the fifth day foIIowing the Iast tapping; he was out of bed on the sixth day and was discharged four days Iater. To date, ApriI 20, 1946, the patient has been perfectly we11 and has carried on his norma pursuits and states that he feels stronger than he has in years. SUMMARY
A case of spontaneous pneumoperitoneum (the sixth) is reported. This is
VOL. LXXIII,
Cunningham-Pneumoperitoneum
No. 6
simiIar to four of the other cases in which there is an accompanying chest condition. This case is unusuaI in that it foIIowed an operative procedure with opening of the peritoneum but at such a late date that there couId be no connection between this and the pathoIogica1 condition present. It aIso paraIIeIs the picture of tension pneumothorax in that the condition became worse and aIso was relieved onIy by remova1 of the air. The presence of a connection between the bronchia tree and the peritoneum seems necessary, in view of the fact that at no time either before or after the operation were there any symptoms
THAT blast injury
are diminished
it an emphysematous both bases. From
1. I II~KEL, CIIARLE~ L.
Spontaneous pneumoperitoneum without dcmonstrabIe visceral perforation. Am. J. Roentgenol., 43: 377-382, 1940. 2. RICLER, L. G. Spontaneous pncumoperitoneum; roentgenological sign found in supine position. Radiology, 37: 604-Go7, 194 I. 3. SIDEL, NORMAN and \VOLBARSHT,AURAHAM. Spontaneous pneumoperitoneum from an unknown cause. New England J. Med., 23 I : 450-452, 1944.
shouId be suspected fuIlness
and impairment
It is usua1 to find the lower chest
region of the Iower costal WiIIiams
REFERENCES
of the diaphragm,
appearance,
“Surgery & Wilkins
when there
of the chest,
of resonance
baIlooned,
giving
at one or
especiaIIy
in the
margin.
of Modern Company).
727
referabIe to the gastrointestina1 tract. AIso, as is seen in tension pneumothorax, the reIease of the air resulted in a breaking of the vicious cycIe and spontaneous recovery. Subsidence occurred spontaneousIy after remova of part of the air.
to the Iungs is present
movements
AmericanJournal of Surgery
\Varfare”
edited
by IIamiIton
BaiIey
(The
SPONTANEOUS JOHN J. CUNNINGHAM,
PNEUMOPERITONEUM M.D.
Chief of the SurgicaI Staff, Our Lady of Lourdes Hospital BINGHAMTON,
T
HE presence of air in the peritoneal cavity is to be expected in any condition in which excess of air is alIowed by injury or perforation of the intestina1 tract or when the peritoneum is opened as in surgica1 or traumatic conditions. Under modern conditions, this has aIso been used in the Rubin test and in peritoneoscopy as we11 as in the introduction of air or other gases for therapeutic or diagnostic reasons. Aside from the symptoms due to the immediate introduction of the air with its accompanying changes in pressure, this is unimportant as the air is absorbed within a comparatively short space of time. The presence of air”is aJso found in peritonitis due to gas forming organisms. Gas or air in the peritonea1 cavity without demonstrabJe reason and in sufficient amounts to cause symptoms is rare. This condition, caIIed “ spontaneous pneumoperitoneum,” has been recorded five times previousIy according to the Iiterature avaiIabIe to the writer. HinkeIl summed up the Iiterature to date in an admirabIe paper and aIso gave in detail the known etioIogy and pathoIogy of the condition. He states : “The intra-abdomina1 pressure is nearIy aIways negative (Wagoner) and, according to SaIkin, it may reach 50 mm. of water beIow that of the atmosphere. The introduction of fluid or air into the peritoneal cavity does not raise the pressure sharpIy because of the ‘abdomina1 accommodation’ described by Coombs. Therefore, if air shouId enter through an aperture in the diaphragm, one could not expect it to be expeIIed through the same route unIess the intra-abdomina1 pressure became greater than that of the atmosphere.” Thus, the presence of air due to perforations of the intestina1 tract or from
NEW YORK
openings to the atmosphere, would be in sufficient amounts to equalize the pressure between the peritoneum and the externa1 source and wouJd not be progressive. According to this idea, the presence of a distention which was sufficient to cause symptoms and progressive enough in nature wouId almost have to be connected in some way with the bronchia tree, barring gasforming organisms or repeated perforations. The mechanism invoIved would be essentiaIIy the same as that in tension pneumothorax, the Iungs being the only pump-Iike mechanism sufficient to produce the extreme pressure deveIoped in the peritonea1 We assume this condition was cavity. caused by a tear through the diaphragm into the bronchia tree, pIus a baII-valve mehanism of the diaphragm. The foIIowing case of spontaneous pneumoperitoneum is the first of its kind to be reported in a patient foIIowing a surgica1 procedure in which the symptoms were so aIarming as to constitute a serious factor in an otherwise norma convaIescence. It corresponds with four of the five cases previousIy reported, in that there was an accompanying chest condition which couId be expIained on the basis of the mechanism noted above (HinkeI). The fifth recorded RigJer,2 was the onIy one in which the symptoms were due to some intestina1 condition. Since perforation of the intestina1 tract with the appearance of air is common and since these are often found onIy at autopsy or at operation, this case (Rigler) whiIe undoubtedIy spontaneous pneumoperitoneum, might very we11 have been due to some perforation. In his patient aIso the symptoms were not progressive and the presence of air was not in sufficient amount to cause serious symptoms.
725
726
FIG.
A merican Journal Of Surgery
I. X-ray
showing Iection
CASE
Cunningham-Pneumoperitoneum
subdiaphragmatic of air.
col-
REPORT
CASE I. D. Y., aged fifty-one, was admitted to Our Lady of Lourdes Hospital because of biIatera1 inguina1 hernias of thirty years’ duration. The patient has been weI1, aside from influenza in 1918 of three weeks’ duration which was folIowed by a chronic bronchitis with attacks of what was diagnosed as bronchial asthma at infrequent intervaIs. There was no history of intestina1 disturbances; his boweIs were regular; he ate everything and used tobacco and alcohol moderateIy. He had always been an out-of-doors man and the only reason he was being operated upon was that he noted that he tired more easiIy especially when he was out hunting or fishing. At operation, done under spina anesthesia, the hernias were repaired by the Bassini technic without diff&Ity. The patient’s condition was good through the procedure and he was returned to his room in exceIIent condition. fluids were aIlowed immediateIy after operation and peniciIIin was started at once. The bowels moved with an enema on the third postoperative day and the patient was eating weI1. ConvaIescence was uneventfu1 unti1 on the fifth postoperative day, when foIIowing an enema, the patient complained of moderate abdominal pain and a sIight chill. His temperature rose t0 IOZOF. ; the abdomen became distended but not aIarmingIy so. He did not vomit and was not nauseated. At this time the wounds were healed and his temperature had been norma for two days. He aIso compIained
JUNB.19.47
of a certain amount of chest distress and had a severe coughing spell. The following day the distention was much more pronounced; however, he \vas taking Iiquids we11 and he stated that he felt fine. An enema was given and returned with a moderate amount of gas and some liquid stoo1; the distention, however, remained constant. His condition remained the same until the next day when the distention was so severe as to cause respiratory embarrassment. He was pIaced in an oxygen tent, but there was no improvement. During this entire period he had no complaints aside from a feeIing of distention. He had no more coughing spells; he was taking Iiquids we11 and enemas were returned with what was considered fair results. The distention, however, reached the point where the abdomen was aImost boardlike to the touch; there was a tympanitic note on percussion. X-ray examination reveaIed the picture seen in Figure I. A diagnosis of pneumo-peritoneum of unknown origin was made and under I per cent novocanine a needIe was inserted into the peritoneum at the Ieft upper quadrant and 3,000 cc. of air was removed with immediate relief. Air was under such pressure as to force the gIass pIunger out of a dry IOO cc. syringe. Suction was not necessary at any time during the procedure. The foIlowing morning the distention had increased from what it had been immediately after the tapping but not to a comparable degree with that seen before. He was again tapped with a trocar and an unmeasured amount of air was withdrawn. A positive pressure was purposely left in order to prevent possibIe vascular symptoms due to the sudden intra-abdominalIy change. Further tappings were not used and the abdomen over a period of ten days graduaIIy became softer unti1 at the time of discharge it was practicaIIy normaI. At no time other than the initia1 insuIt was there an elevation in temperature. The patient sat on the edge of the bed on the fifth day foIIowing the Iast tapping; he was out of bed on the sixth day and was discharged four days Iater. To date, ApriI 20, 1946, the patient has been perfectly we11 and has carried on his norma pursuits and states that he feels stronger than he has in years. SUMMARY
A case of spontaneous pneumoperitoneum (the sixth) is reported. This is
VOL. LXXIII,
Cunningham-Pneumoperitoneum
No. 6
simiIar to four of the other cases in which there is an accompanying chest condition. This case is unusuaI in that it foIIowed an operative procedure with opening of the peritoneum but at such a late date that there couId be no connection between this and the pathoIogica1 condition present. It aIso paraIIeIs the picture of tension pneumothorax in that the condition became worse and aIso was relieved onIy by remova1 of the air. The presence of a connection between the bronchia tree and the peritoneum seems necessary, in view of the fact that at no time either before or after the operation were there any symptoms
THAT blast injury
are diminished
it an emphysematous both bases. From
1. I II~KEL, CIIARLE~ L.
Spontaneous pneumoperitoneum without dcmonstrabIe visceral perforation. Am. J. Roentgenol., 43: 377-382, 1940. 2. RICLER, L. G. Spontaneous pncumoperitoneum; roentgenological sign found in supine position. Radiology, 37: 604-Go7, 194 I. 3. SIDEL, NORMAN and \VOLBARSHT,AURAHAM. Spontaneous pneumoperitoneum from an unknown cause. New England J. Med., 23 I : 450-452, 1944.
shouId be suspected fuIlness
and impairment
It is usua1 to find the lower chest
region of the Iower costal WiIIiams
REFERENCES
of the diaphragm,
appearance,
“Surgery & Wilkins
when there
of the chest,
of resonance
baIlooned,
giving
at one or
especiaIIy
in the
margin.
of Modern Company).
727
referabIe to the gastrointestina1 tract. AIso, as is seen in tension pneumothorax, the reIease of the air resulted in a breaking of the vicious cycIe and spontaneous recovery. Subsidence occurred spontaneousIy after remova of part of the air.
to the Iungs is present
movements
AmericanJournal of Surgery
\Varfare”
edited
by IIamiIton
BaiIey
(The