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How to distinguish between surgical and non-surgical pneumoperitoneum?


1Department of Surgery, Faculty of Medicine and University Hospital Hradec Králové

2Department of Field Surgery, Military Health Science Faculty Hradec Králové Defence University Brno

DOI: 10.22514/SV91.042014.1 Vol.9,Issue 1,April 2014 pp.9-15

Published: 30 April 2014

*Corresponding Author(s): FILIP ČEČKA E-mail:


Not all cases of pneumoperitoneum found on abdominal X-ray or computed tomography (CT) scan are caused by hollow viscus perforation. Non-surgical or spontaneous pneumoperitoneum is a repeatedly described entity. However, not all physicians in emergency departments are aware of it, and in such cases unnecessary laparotomy is often performed which reveals no intra-abdominal pathology. Non-surgical pneumoperitoneum can have thoracic, abdominal, gynecological, or other causes. When we acknowledge the possibility of non-surgical pneumoperitoneum, the primary goal is to discern sur-gical from non-surgical pneumoperitoneum. Identifying cases in which laparotomy can be avoided is important to prevent unnecessary surgery and its associated morbidity and financial costs. In this paper we propose a practical algorithm which may help the attending physicians to distinguish between surgical and non-surgical pneumoperitoneum. 


non-surgical pneumo-peritoneum, postoperative pneumo-peritoneum, positive end-expiratory pressure, endoscopy, percutaneous endoscopic gastrostomy, peritoneal dialysis, postcoital pneumoperito-neum

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FILIP ČEČKA,OTAKAR SOTONA,ZDENÌK ŠUBRT. How to distinguish between surgical and non-surgical pneumoperitoneum?. Signa Vitae. 2014. 9(1);9-15.


1. Dandy WE. Pneumoperitoneum: a Method of Detecting Intestinal Perforation-an Aid in Abdominal Diagnosis. Ann Surg 1919;70:378-83.

2. Winek TG, Mosely HS, Grout G, Luallin D. Pneumoperitoneum and its association with ruptured abdominal viscus. Arch Surg 1988;123:709-12.

3. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713-6.

4. Beintaris I, Polymeros D, Papanikolaou IS, Kontopoulou C, Kourikou A, Sioulas AD, et al. Fatal perforation with subcutaneous emphysema complicating ERCP. Endoscopy 2012;44 Suppl 2 UCTN:E313-4.

5. Mason JM, Mason EM, Kesmodel KF. Spontaneous pneumoperitoneum without peritonitis and without demonstrable cause. South Med J 1946;39:620-4.

6. Freitas Junior WR, Malheiros CA, Kassab P, Ilias EJ. Idiopathic spontaneous pneumoperitoneum. Rev Assoc Med Bras 2011;57:614.

7. Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of pneumoperitoneum. West J Med 1999;170:41-6.

8. Williams NM, Watkin DF. Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas. Postgrad Med J 1997;73:531-7.

9. Hillman KM. Pneumoperitoneum--a review. Crit Care Med 1982;10:476-81.

10. Canivet JL, Yans T, Piret S, Frere P, Beguin Y. Barotrauma-induced tension pneumoperitoneum. Acta Anaesthesiol Belg 2003;54:233-6.

11. Krausz M, Manny J. Pneumoperitoneum associated with pneumothorax: a surgical dilemma in the post-traumatic patient. J Trauma 1977;17:238-40.

12. Lee CH, Kim JH, Lee MR. Postoperative pneumoperitoneum: guilty or not guilty? J Korean Surg Soc 2012;82:227-31.

13. Spinelli N, Nfonsam V, Marcet J, Velanovich V, Frattini JC. Postoperative pneumoperitoneum after colorectal surgery: Expectant vs surgical management. World J Gastrointest Surg 2012;4:152-6.

14. Gayer G, Jonas T, Apter S, Amitai M, Shabtai M, Hertz M. Postoperative pneumoperitoneum as detected by CT: prevalence, duration, and relevant factors affecting its possible significance. Abdom Imaging 2000;25:301-5.

15. Millitz K, Moote DJ, Sparrow RK, Girotti MJ, Holliday RL, McLarty TD. Pneumoperitoneum after laparoscopic cholecystectomy: frequency and duration as seen on upright chest radiographs. AJR Am J Roentgenol 1994;163:837-9.

16. Gasparetto M, Giorgi B, Kleon W, Al Bunni F, Guariso G. Colonic perforation in a child with Crohn's disease: successful medical treatment rescues from colectomy. Case Rep Gastrointest Med 2012;2012:152414.

17. Makni A, Chebbi F, Ben Safta Z. Pneumoretroperitoneum, bilateral pneumothorax and emphysema following endoscopic biliary sphincte-rotomy. Acta Chir Belg 2012;112:307-9.

18. Sagawa T, Kakizaki S, Iizuka H, Onozato Y, Sohara N, Okamura S, et al. Analysis of colonoscopic perforations at a local clinic and a tertiary hospital. World J Gastroenterol 2012;18:4898-4904.

19. Fujii L, Lau A, Fleischer DE, Harrison ME. Successful Nonsurgical Treatment of Pneumomediastinum, Pneumothorax, Pneumoperitoneum, Pneumoretroperitoneum, and Subcutaneous Emphysema following ERCP. Gastroenterol Res Pract 2010;2010:289135.

20. Ionescu C, Ecobici M, Olaru D, Stanescu C, Lupescu I, Voiculescu M. Pneumoperitoneum--rare complication in end stage renal disease patient on automated peritoneal dialysis. Rom J Intern Med 2008;46:351-5.

21. Kiefer T, Schenk U, Weber J, Hubel E, Kuhlmann U. Incidence and significance of pneumoperitoneum in continuous ambulatory peritoneal dialysis. Am J Kidney Dis 1993;22:30-5.

22. Huang JW, Peng YS, Wu MS, Tsai TJ. Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: difficulty in diagnosis. Am J Kidney Dis 1999;33:e6.

23. Blum CA, Selander C, Ruddy JM, Leon S. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. Am Surg 2009;75:39-43.

24. Wiesen AJ, Sideridis K, Fernandes A, Hines J, Indaram A, Weinstein L, et al. True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study. Gastrointest Endosc 2006;64:886-9.

25. Cyrany J, Kopacova M, Rejchrt S, Ryska A, Dvorak P, Brozik J, et al. Pneumatosis cystoides intestinalis. Acta Endosc 2011;41:243-52.

26. Arikanoglu Z, Aygen E, Camci C, Akbulut S, Basbug M, Dogru O, et al. Pneumatosis cystoides intestinalis: a single center experience. World J Gastroenterol 2012;18:453-7.

27. Azzaroli F, Turco L, Ceroni L, Galloni SS, Buonfiglioli F, Calvanese C, et al. Pneumatosis cystoides intestinalis. World J Gastroenterol 2011;17:4932-6.

28. Jacobs VR, Mundhenke C, Maass N, Hilpert F, Jonat W. Sexual activity as cause for non-surgical pneumoperitoneum. Jsls 2000;4:297-300.

29. Lovecek M, Herman J, Svach I, Gryga A, Duda M. Postcoital pneumoperitoneum after hysterectomy. Surg Endosc 2001;15:98.

30. Spaulding LB, Gallup DG. Pneumoperitoneum after hysterectomy. Jama 1979;241:825.

31. Tabrisky J, Mallin LP, Smith JA, 3rd. Pneumoperitoneum after coitus. A complication due to uterine tube prolapse after vaginal hysterec-tomy. Obstet Gynecol 1972;40:218-20.

32. Varon J, Laufer MD, Sternbach GL. Recurrent pneumoperitoneum following vaginal insufflation. Am J Emerg Med 1991;9:447-8.

33. Daly BD, Guthrie JA, Couse NF. Pneumoperitoneum without peritonitis. Postgrad Med J 1991;67:999-1003.

34. Gantt CB, Jr., Daniel WW, Hallenbeck GA. Nonsurgical pneumoperitoneum. Am J Surg 1977;134:411-4.

35. Lyness JR, Bentley AJ. Air embolism during sexual intercourse in the puerperium. Am J Forensic Med Pathol 2010;31:247-9.

36. Williams TC, Kanne JP, Lalani TA. Jacuzzi jet-induced pneumoperitoneum. Emerg Radiol 2004;10:259-61.

37. Bunni J, Bryson PJ, Higgs SM. Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver. Ann R Coll Surg Engl 2012;94:e237-9.

38. Dodek SM, Friedman JM. Spontaneous pneumoperitoneum. Obstet Gynecol 1953;1:689-98.

39. Lozman H, Newman AJ. Spontaneous pneumoperitoneum occurring during postpartum exercises in the knee-chest position. Am J Obstet Gynecol 1956;72:903-5.

40. Wright AR. Spontaneous pneumoperitoneum. AMA Arch Surg 1959;78:500-2.

41. Kim JH, Jung ES, Jeong SH, Kim JS, Ku YS, Hahm KB, et al. A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma. Korean J Hepatol 2012;18:94-7.

42. London NJ, Bailey RG, Hall AW. Spontaneous benign pneumoperitoneum complicating scleroderma in the absence of pneumatosis cystoides intestinalis. Postgrad Med J 1990;66:61-2.

43. Vischio J, Matlyuk-Urman Z, Lakshminarayanan S. Benign spontaneous pneumoperitoneum in systemic sclerosis. J Clin Rheumatol 2010;16:379-81.

44. Ukikusa M, Inomoto T, Kitai T, Ino K, Higashiyama H, Arimoto A, et al. Pneumoperitoneum following the spontaneous rupture of a gas-containing pyogenic liver abscess: report of a case. Surg Today 2001;31:76-9.

45. Andreone P, L'Heureux P, Strate RG. An unusual cause of massive non-surgical pneumoperitoneum: case report. J Trauma 1989;29:1286-8.

46. Uva JL. Spontaneous pneumothoraces, pneumomediastinum, and pneumoperitoneum: consequences of smoking crack cocaine. Pediatr Emerg Care 1997;13:24-6.

47. Clements WD, Gunna BR, Archbold JA, Parks TG. Idiopathic spontaneous pneumoperitoneum--avoiding laparotomy--a case report. Ulster Med J 1996;65:84-6.

48. Masood QF, Khaleeq T, Khan Q, Abbasi S, Arshad S, Bano F, et al. A case of non-surgical pneumoperitonium: gas under the diaphragm. J Ayub Med Coll Abbottabad 2009;21:176-7.

49. Brill SE, Skipworth J, Stoker DL. Conservative management of pneumatosis intestinalis and massive pneumoperitoneum in the acute abdomen: a case report. Ann R Coll Surg Engl 2008;90:W11-3.

50. Freeman RK. Pneumoperitoneum from oral-genital insufflation. Obstet Gynecol 1970;36:162-4.

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