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 ::  Abstract
 ::  Introduction
 ::  Case report
 ::  Discussion
 ::  References

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CASE REPORTS
Year : 1992  |  Volume : 38  |  Issue : 2  |  Page : 84-5

Benign neonatal pneumoperitoneum--an enigma.


Dept of Paediatric Surgery, KEM Hospital, Parel, Bombay, Maharashtra.,

Correspondence Address:
R S Shah
Dept of Paediatric Surgery, KEM Hospital, Parel, Bombay, Maharashtra.

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PMID: 0001432837

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 :: Abstract 

A case of neonatal pneumoperitoneum in absence of a bowel perforation or intrathoracic pathology has been reported. The cause of such a rare manifestation remains to be established.


Keywords: Case Report, Human, Infant, Newborn, Male, Pneumoperitoneum, etiology,radiography,surgery,


How to cite this article:
Shah R S, Patel M P, Pikale H S, Kulkarni B K, Borwankar S S. Benign neonatal pneumoperitoneum--an enigma. J Postgrad Med 1992;38:84

How to cite this URL:
Shah R S, Patel M P, Pikale H S, Kulkarni B K, Borwankar S S. Benign neonatal pneumoperitoneum--an enigma. J Postgrad Med [serial online] 1992 [cited 2014 Aug 23];38:84. Available from: http://www.jpgmonline.com/text.asp?1992/38/2/84/710





  ::   Introduction Top


Pneumoperitoneum in a newborn is almost always interpreted as evidence of rupture of a hollow viscus.

As pneumoperitoneum signals gastrointestinal perforation, prompt laparotomy is generally required. However, pneumoperitoneum on rare occasions can present without any gastrointestinal leak i.e. infants with acute respiratory distress with interstitial pneumonia can develop pneumoperitoneum. We report a case of neonatal pneumoperitoneum without any established cause.


  ::   Case report Top


A 26-year-old primigravida without any abnormal obstetric history gave birth to a male child at 36 weeks of gestation. The birth weight of the newborn was 2.3 kg. The delivery was normal and the child had an Apgar score of 8 and 10 at 1 and 5 minutes, respectively. The child was absolutely alright after birth without any evidence of respiratory problems. The child passed meconium on the first day of life and was taking feeds adequately.

On the fifth day, the child presented to us with abdominal distension of one day duration. There was no other significant history. On examination, the child seemed to be comfortable and the chest was clear. The abdomen apart from mild distension did not have any findings suggestive of peritonitis. The per rectal catheter was stained with milk stools. The vertical X-ray revealed free gas under both the domes of diaphragm with a few distended bowel loops. The chest was absolutely clear. With the X-ray findings, we decided to go ahead with an exploratory laparotomy.

At laparotomy to our surprise the entire gastrointestinal tract was normal and apart from the gas, there was no free fluid or pus in the peritoneal cavity. The lesser sac was opened and the duodenum was inspected thoroughly and the abdomen was closed in layers.

The postoperative course was uneventful. The child was started on feeds after 36 hours and was discharged from the hospital on the fourth post-operative day.


  ::   Discussion Top


The roentgenographic demonstration of free intraperitoneal air has become a refined art. In 1938, it was thought that minimum air volume detectable in an average individual was 20-30 ml[2]. Twenty years later, 10ml was readily demonstrable in several children. Finally, Miller and 3 Nelson were able to detect 1 ml of intraperitoneal air[3].

Pneumoperitoneum in the newborn most commonly arises from a perforated hollow viscus[4]. Gastric and duodenal ulcer perforations, idiopathic gastric necrosis, and necrosis of small intestine or colon secondary to necrotising enterocolitis, intestinal atresia, volvulus, meconium ileus, Hirschsprung's disease or Meckel's diverticulum all require operative management. On the other hand, operation should be deferred when pneumoperitoneum occurs as a result of pulmonary interstitial air. Benign pneumoperitoneum has been reported secondary to pneumothorax or pneumomediastinum in association with positive pressure ventilation.

A preceding abdominal operation is the most common cause of pneumoperitoneum[5]. Pneumoperito-neum without peritonitis, unrelated to antecedent laparotomy has been called spontaneous or idiopathic, but these terms tend to promote an air of mystery[5]. A paracentesis can cause a pneumoperitoneum in the absence of any disease. Severe straining and coughing can some times lead to pneumoperitoneum following pneumomediastinum. Pneumoselective perforations of the gastrointestinal tract have an inherent aspect of incredibility, but there is an overwhelming testimony supporting their occasional occurrence especially after gastroscopy and air contrast enema[5].

Primary pneumatosis intestinalis though quite rare in children, can cause pneumoperitoneum. Radiographic pneumoperitoneum simulated by adventitious X-ray shadows have also been reported[5].

In this report, we have a case of benign neonatal pneumoperitoneum unassociated with any intrathoracic pathology, but the odds strongly favour operative investigation. The child underwent an unnecessary laparotomy, but no great harm is likely to befall him from this over concern on the part of the surgeon. It would be far better to heed the advice of Zeta[6]. “More harm is done because you do not look; than from not knowing what is in the book”.

 
 :: References Top

1. Brown DR, Keenan WI. Pneumoperitoneum without gastrointestinal perforation in a neonate. J Paediatr 1974; 85:377-379.  Back to cited text no. 1    
2.Paine JR, Rigler LG. Pneumoperitoneum in perforations of the gastrointestinal tract. Surgery 1983; 3:551-557.  Back to cited text no. 2    
3.Miller RE, Nelson SW. The roentgenologic demonstration of tiny amounts of free intraperitoneal gas, experimental and clinical studies. Am J Roentgenol 1971; 112:574-579  Back to cited text no. 3    
4.Zarella, JT McGullough JY. Pneumoperitoneum in infants without gastrointestinal perforation. Surgery 1982; 89:163-167.  Back to cited text no. 4    
5.Chandler JO, Berk RN, Golden GT. Misleading pneumoperitoneum. Surg Gynaec Obst 1977; 144:163-174.   Back to cited text no. 5    



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1 Spontaneous gastric perforation in a neonate. A case report
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