What's the Diagnosis? By Dr. Karen O'Brien

A 66 yo M w/ history of prior duodenal perforation s/p numerous graham patch repairs and prior endovascular aortic repair presents to the ED w/ altered mental status and hypotension w/ a SBP in 60s. He is emergently intubated. RUSH exam is done and free fluid is noted in the abdomen. His post-intubation CXR is shown below. What's the diagnosis? (scroll down for answer)






Answer: Pneumoperitoneum

  • Etiology
    • Trauma: local via iatrogenic (cautery, instrumentation), blunt, penetrating
    • Bowel obstruction: occurs proximal to obstruction due to increase in pressure on bowel wall (leads to ischemic necrosis, wall breakdown)
    • Spontaneous: medication related, connective tissue disorders, inflammation
  • Free air in peritoneum --> leads to decreased diaphragmatic excursion --> respiratory distress
  • Watch for abdominal compartment syndrome as well as mediastinal air/crepitus
  • Additional imaging:  CT can identify location of perforation 
  • Initial ED management: IVF, broad spectrum antibiotics, NPO, immediate surgical consult
    • surgery may decide directly to OR for exploration/drainage vs CT imaging
  • Dispo: ICU




Addison NV, Broughton AC. Tension pneumoperitoneum: a report of 4 cases. Br J Surg. 1976 Nov;63(11):877-80. doi: 10.1002/bjs.1800631111. PMID: 1000185. 


Sarr MG, Pemberton JH, Payne WS. Management of instrumental perforations of the esophagus. J Thorac Cardiovasc Surg. 1982 Aug;84(2):211-8. PMID: 7098508.