[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.

Pneumatosis cystoides intestinalis coli.

The rare case of a 63-year-old male diagnosed with pneumatosis cystoides intestinalis coli is presented and discussed. The patient was found to have an unsymptomatic pneumoperitoneum on plain chest x-ray. The results of a contrast enema, computed tomography scan, and laparoscopy are presented. The patient had an uneventful hospital course without any specific therapy. Causes and possible therapeutic options are discussed.

[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.