When not to operate with significant pneumoperitoneum as an emergency surgeon

Abstract text (incl. references and figure legends)

Case History

A 83 old man reffered to our District General Hospital following a CT Abdomen and Pelvis with large pneumoperitoneum, Ct was conducted in a different tertiary center 4 days ago

Clinical findings

The patient was clinically asymptomatic and his bloods were unremarkable with normal crp

Investigations / Result

His Ct Abdomen and pelvis with contrast showed evidence of bowel perforation and intramural gas effecting mainly jejunum area indicative of ischemic changes

Diagnosis

Radiologically there was suspicion of bowel perforation and evidence of intramural gas mainly jejunal loop suspicious of ischemic changes . There was impression of linear filling defect in superior mesenteric artery which raised supicion of thrmbus

Therapy and Progression

After careful multi disciplinary meetings and discussions with radiologist and CT scans with oral contrasts he was managed conservatively and discharged after 2 weeks with a further repeat Ct scan .

Comments

Despite radiological evidence of extensive pneumoperitoneum, the patient was clinically stable with no abdominal signs, therefore he was managed with close observation, repeat bloods, and radiological imaging, rather than agressive operative approach

Team approach, discussion with colleagues, careful monitoring of lactate, inflammatory markers, nutritional support, Ct with oral and intravenous contrast can save negative laprotomy in sub group of elderly patients with multiple co-morbidities like in our case where our pateint was having prostate cancer and multiple metastasis.

References

Int J Surg Case Rep . 2019;63:10-12.doi: 10.1016/j.ijscr.2019.08.015. Epub 2019 Aug 17.

The clinical dilemma of the persistent idiopathic pneumoperitoneum: A case report

Enda Hannan ¹, Eltaib Saad ², Shu Hoashi ², Desmond Toomey ^{2 1}Department of General Surgery, Regional Hospital Mullingar, Ireland. Electronic address: endahannan@rcsi.ie. PMID: 31499325 PMCID: PMC6734534 DOI: 10.1016/j.ijscr.2019.08.015

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