[A simple home remedy for heartburn led to a life-threatening rupture of the stomach]. / Huskur mot halsbränna ledde till livshotande ventrikelruptur.

A middle-aged male who suffered from heartburn ingested 1 tablespoon of bicarbonate dissolved in water to relieve symptoms. Minutes afterwards he debuted with severe abdominal pain. Upon arrival at hospital 35 minutes later he was septic with peritonitis. Surgery without preoperative radiology was contemplated. However, a promptly available CT-scan interpreted by a radiologist revealed small amounts of pneumoperitoneum. During laparotomy findings were minor and the anticipated perforation could not be localized. However, after extensive air insufflation with a gastroscope a perforation below the gastroesophageal junction was detected.  This case illustrates how a seemingly harmless home remedy resulted in a life-threatening condition. During night-time in Sweden, primary radiological services are often only offered digitally by remote radiologists. Such a remote organization at our hospital might have resulted in omitting CT to avoid delay, but with an increased risk of misdiagnosing our patient.

Sonographic Evaluation and Monitoring of Pneumoperitoneum After Air Enema Reduction for Intussusception.

Abdominal radiography and computed tomography scans are standard tests to diagnose pneumoperitoneum. With the growing availability of point-of-care ultrasound, pneumoperitoneum may be diagnosed in settings without easy access to radiography or computed tomography, such as in overcrowded emergency departments or resource-poor environments. The use of point-of-care ultrasound to diagnose or monitor pneumoperitoneum has been described in adult but not pediatric patients. We present a case of point-of-care ultrasound detection of pneumoperitoneum and monitoring for tension pneumoperitoneum, after failed air enema reduction for intussusception in an infant.

Successful treatment of pneumatosis intestinalis with associated pneumoperitoneum and ileus with hyperbaric oxygen therapy.

Pneumatosis intestinalis (PI), or the presence of air in the bowel wall, is a rare disorder that is associated with a variety of underlying diseases, including connective tissue disorders. PI presents on a spectrum from asymptomatic to bowel obstruction and acute abdomen. In general, treatment of PI consists of treating the underlying disease. Both normobaric and hyperbaric oxygen have been used to treat PI directly. Here we report a symptomatic scleroderma-related case of PI that responded clinically to hyperbaric oxygen therapy. This report adds to a growing body of literature supporting a role for hyperbaric oxygen therapy in symptomatic PI.

Safety Concerns with Thoracoabdominal Acupuncture: Experience at a Tertiary-Care Emergency Department.

OBJECTIVE: To evaluate serious complications caused by acupuncture treatment and to increase awareness of this complication. DESIGN: A retrospective observational study. SETTING: At the emergency department of a tertiary hospital in an urban area during a five-year period (2010-2014) in Seoul, Korea. SUBJECTS: Patients with postacupuncture mechanical complications in the thoracoabdominal region. METHODS: All cases were independently assessed for inclusion by two emergency physicians based on the causal relationship between acupuncture and emergency department presentation. RESULTS: There were 10 cases of pneumothorax (one combined with pneumomediastinum) and two cases of pneumoperitoneum induced by acupuncture. Five of the 12 patients were male; the mean age was 43.4 years. The mean time between acupuncture and emergency department admission was 1.6 days. The pneumothorax was unilateral in eight cases and bilateral in two. Eight patients underwent tube thoracostomy (pig tail catheter or chest tube insertion) and were admitted to the hospital for a median of 11 days. Of the two patients with pneumoperitoneum, one was transferred to another hospital for emergency surgery and the other was admitted to our hospital after emergency total colectomy. CONCLUSIONS: Life-threating complications such as pneumothorax and bowel perforation after acupuncture can occur, and this suggests that physicians, especially acupuncturists, should be aware of the risk associated with needling around the trunk region. To maximize the safety of acupuncture, adequate competency-based training should be provided.

[Pneumoperitoneum after jacuzzi bathing -- an unusual cause for the development of intraperitoneal free air]. / Jacuzzihasználatot követoen kialakult pneumoperitoneum, avagy a szabad hasi levego keletkezésének ritka esete.

Free air within the intraperitoneal cavity most frequently occurs in conjunction with perforation of a hollow viscus and requires urgent surgical intervention. However, approximately 10% of all cases of pneumoperitoneum may not be correlated with disruption of the gastroinestinal tract. In the literature this condition is termed "nonsurgical" (NS) pneumoperitoneum and usually requires conservative management. NS pneumoperitoneum can be classified into the following categories: abdominal, thoracic, gynecologic, and idiopathic. We present a rare case of NS pneumoperitoneum. A 61-year-old woman who underwent a hysterectomy previously is admitted with diffuse abdominal pain without any other symptoms. Chest and abdominal radiographs verified the presence of free air under the diaphragm. We performed an exploration but no evidence of perforated viscus or peritonitis was found. Finally the patient told us that her complaints developed during Jacuzzi usage. We thought therefore that air entered into the intraperitoneal cavity through the vagina by influence of high pressure douche. In the course of postoperative gynecological examination a vaginoperitoneal fistula was detected in the vault which is developed during Jacuzzi usage leading to NS pneumoperitoneum. Essentially, NS pneumoperitoneum usually occurs without signs and symptoms of peritonitis and requires conservative treatment. Detailed physical examination and medical history taking can help to avoid unnecessary surgery in spite of radiological evidence of intraperitoneal free air.

Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception.

BACKGROUND: The contemporary management of children with ileocolic intussusception often includes pneumatic reduction. While failure of the procedure or recurrence after reduction can result in the need for surgical treatment, more serious adverse sequelae can occur including perforation and, rarely, tension pneumoperitoneum. During the last year, four cases of perforation during attempted pneumatic reductions complicated by tense pneumoperitoneum have occurred in our center. OBJECTIVE: We have elected to report our patient experience, describe methods of management and review available literature on this uncommon but serious complication. MATERIALS AND METHODS: Using ICD-9 diagnosis codes, we reviewed the records of children with intussusception during 2011. Demographic and therapeutic clinical data were collected and summarized. RESULTS: During the study period, 101 children with intussusception were treated at our institution, with 19% (19/101) of them requiring surgical intervention. Four children (4%) experienced a tense pneumoperitoneum during air enema reduction, prompting urgent needle decompression in the fluoroscopy suite. These children required bowel resection during subsequent laparotomy. No deaths occurred. CONCLUSION: Pneumoperitoneum is a real and life-threatening complication of pneumatic enemas. It requires immediate intervention and definitive surgical management. Caution should be exercised by practitioners performing this procedure at institutions where pediatric radiology experience is limited and immediate pediatric surgical support is not available.

Pneumatosis cystoides intestinalis in scleroderma-related conditions.

AIMS: Pneumatosis cystoides intestinalis (PCI) is a rare life-threatening gastrointestinal complication in the course of connective tissue disease (CTD). PCI is characterised by the appearance of intramural clusters of gas in the small and large bowel wall on X-ray or computed tomography and often is accompanied by free air in the peritoneal cavity. METHODS: We present three cases of PCI in patients with scleroderma-related conditions. A review of the English language literature published on MEDLINE from 1973 to 2008 was conducted using the terms: 'systemic sclerosis', 'connective tissue disease' and 'pneumatosis cystoides intestinalis'. This review focused on clinical features, diagnostic and treatment strategies of PCI in the context of CTD. RESULTS: Symptoms of PCI are non-specific: abdominal pain, vomiting, constipation, bloating and weight loss. Coexistence of PCI with other manifestations of CTD, such as intestinal pseudo-obstruction and/or bacterial overgrowth, complicates the clinical diagnosis. Treatment approach to PCI is mostly conservative: intestinal 'rest', parenteral nutrition, antibiotics, fluids and electrolyte supplementation, and inhaled oxygen. Surgical intervention should be performed only in cases of bowel perforation, ischaemia or necrosis. Patients with PCI have high mortality rates due to PCI itself but also to the severity and variety of basic CTD complications. CONCLUSION: Recognition of PCI, particularly in the context of underlying CTD, is necessary for proper therapeutic application. In patients with underlying CTD and symptoms of abdominal emergency, recruitment of multidisciplinary teams, including rheumatologist, gastroenterologist, imaging specialist and surgeons familiar with intestinal complications of CTD-related conditions, is warranted.

Jacuzzi jet-induced pneumoperitoneum.

Pneumoperitoneum outside the setting of recent surgical intervention usually indicates perforation of the gastrointestinal tract. Following radiologic evidence of pneumoperitoneum, surgical exploration of the abdomen may be indicated depending on the nature of the patient's presentation. We present the radiological findings of a healthy young woman who presented with acute onset of abdominal pain and was found to have extensive pneumoperitoneum. No visceral disruption was evident by multidetector CT or by single-contrast barium fluoroscopic evaluation of the upper gastrointestinal tract. Knowledge of benign causes of pneumoperitoneum by the radiologist may avert an unnecessary laparotomy.

Perforación colónica durante la realización de enema de bario / Colonic perforation in the course of a varium enema

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[Pneumoperitoneum as occasional finding in chronic dialysis patients--laparotomy or conservative non-operative approach?]. / Das Pneumoperitoneum als Zufallsbefund bei chronischen Dialysepatienten--zwingende Indikation zur Laparotomie oder mögliche konservative Therapie?

Free air of unknown origin within the abdominal cavity is a serious problem, which in the majority of cases indicates the perforation of a hollow organ. In two cases, we report on i) detection of free air subdiaphragmatically by coincidence during follow-up investigation of an interstitial pulmonary disease (chest X-ray) in a 67-year old patient with chronic renal insufficiency, and ii) diagnostic of pneumoperitoneum (3 times as primary diagnosis) in a 63-year old multimorbid female (with chronic renal insufficiency) with recurrent, but unspecific epigastric symptoms over a time period of 5 years. The following investigations such as endoscopy, contrast enema, and abdominal ultrasound did not detect a perforation as most likely cause. The first patient was discharged after clinical observation, laboratory and ultrasound follow-up for 5 days. In the second case, neither explorative laparoscopy during the second clinical observation period nor laparotomy for required cholecystectomy because of cholecystitis could appropriately clarify the origin. In conclusion, the detection of a pneumoperitoneum in asymptomatic patients or subjects with unspecific abdominal symptoms requires always clinical monitoring and instrumental diagnostic, consisting of endoscopy in the upper gastrointestinal tract, contrast enema of the colon and abdominal and/or thoracal computed tomography, to definitely exclude perforation. In addition, ultrasound as third column detects early low amounts of fluid and is the suitable method for short-term follow-up. The cause of pneumoperitoneum, particularly in asymptomatic patients, can not be found in every case. Under these circumstances, non-operative treatment is favored.

Pneumoperitoneum following Jacuzzi usage.

A 56-year-old woman presented with abdominal pain after using a Jacuzzi hours earlier. Abdominal radiographs revealed intra-peritoneal free gas and, as she presented symptomatically, a laparotomy was performed. This revealed fluid and gas but no visceral perforation or intra-abdominal pathology to account for this. Peritoneal lavage was performed and the patient made an unremarkable recovery. Various causes of pneumoperitoneum have been described in the literature and both conservative and operative treatment recommended. We are unaware of any other reports of Jacuzzi-induced pneumoperitoneum and describe it as an entity to be considered in abdominal pain secondary to the use of similar types of device.

[Retroperitoneal abscess formation accompanied by intraabdominal free air, a rare complication of transcatheter arterial embolization of renal tumor: a case report].

Transcatheter arterial embolization (TAE) has been commonly used in the treatment of renal cancer. Postembolization syndrome consisting of fever, flank pain and gastrointestinal symptoms is encountered in almost every case. We report a case of E. coli-induced retroperitoneal abscess accompanied by intraabdominal free air which developed three weeks after TAE in a 59-year-old woman with T4N0M0 renal cancer. No fistula between abscess and gastrointestinal tract could be demonstrated by gastrofiberscopy and barium enema. Urine culture just before TAE should be examined to avoid such a complication.

The radiology of necrotizing enterocolitis.

Imaging of necrotizing enterocolitis is frustrating, with no single imaging test that is both sensitive and specific for the diagnosis. Early, nonspecific findings on plain abdominal films before development of pneumatosis intestinalis is enough evidence in the proper clinical setting to institute medical treatment of necrotizing enterocolitis. Subsequent development of pneumatosis intestinalis will help confirm the clinical diagnosis, but treatment should not be withheld for its development. Delayed complications of necrotizing enterocolitis can be diagnosed by contrast enema examinations, and ultrasound is a helpful additional test in equivocal cases.

Pneumoperitoneum secondary to pneumocolon examination.

A patient had pneumoperitoneum after an air contrast barium examination. We therefore reviewed perforations secondary to barium enema examinations and concluded that conservative management of this most unusual complication may be considered if there is no evidence of barium extravasation and if the clinical course is benign.

Giant colonic diverticulum.

Five patients with giant colonic diverticulum (GCD) are reported. Three of them had complications of the GCD including free perforation with pneumoperitoneum and peritonitis and an instance of carcinoma arising in a GCD. The preoperative diagnosis of GCD is made radiographically with findings of a large, smoothly marginated, round or oval, homogenous radiolucency in the abdomen that is in close apposition to the colon on barium enema examination. Barium enters the GCD in 60% of the cases. Most GCDs are considered to be pseudodiverticula; however, an occasional case may have all layers of bowel in the wall of the diverticulum and is believed to represent a true diverticulum or a communicating partial colonic duplication.

Pneumoperitoneum occurring during double-contrast enema.

A case of pneumoperitoneum occurring during double-contrast barium enema is described. Cases reported to date indicate that colonic rupture during a double-contrast enema is likely to result in exit of air rather than barium from the colon. The diagnostic implicatons of this observation are considered. The potentially high pressure generated by bulb-type inflators is discussed, and caustion is advised against overdistending the colon during double-contrast enemas.