[Pneumatosis cystoides intestinalis: a case report and literature review]. / Kistoznyi pnevmatoz tonkoi kishki: klinicheskii sluchai i obzor literatury.

Pneumatosis cystoides was first described by Du Vernay in 1783. This is a fairly rare disease with nonspecific symptoms and CT data on pneumoperitoneum. The authors present pneumatosis intestinalis in a patient with systemic connective tissue disorder. Free gas in abdominal cavity and dilated intestinal loops were an indication for emergency surgery with subsequent resection of intestine due to signs of ischemic damage. A review of clinical cases allows us to conclude that pneumoperitoneum requires careful differential diagnosis. Free gas in abdominal cavity in patients with cystic pneumatosis is an indication for emergency surgery only in case of complicated course of disease.

[Spontaneous idiopathic pneumoperitoneum in a patient with COVID-19]. / Spontannyi idiopaticheskii pnevmoperitoneum u patsienta s COVID-19.

The authors present a patient with COVID-19 and spontaneous idiopathic pneumoperitoneum. A 77-year-old man suffering from coronary artery disease, diabetes mellitus and cognitive disorders was diagnosed with bilateral pneumonia and COVID-19. Oxygen support through a face mask was prescribed. After 21 days, oxygen saturation decrease and mild abdominal symptoms required CT-based examination. Pneumoperitoneum without pneumothorax and pneumomediastinum was revealed. Explorative laparotomy found no abdominal diseases. According to the literature, spontaneous pneumoperitoneum in patients with COVID-19 is usually associated with high pressure oxygen therapy, but not always associated with intrathoracic complications. Conservative treatment may be appropriate in patients with spontaneous pneumoperitoneum, but any unclear findings can require surgery.

Emphysematous Cystitis and Pneumoperitoneum in a Dog with Escherichia coli Urinary Tract Infection and Hyperadrenocorticism.

A 9 yr old male neutered Staffordshire bull terrier with a history of poorly controlled hyperadrenocorticism, urinary tract infections, and emphysematous cystitis (EC) was presented to a veterinary referral teaching hospital for vomiting. Abdominal radiographs revealed EC and a pneumoperitoneum. The urinary bladder was found to be intact based on ultrasound and a pre- and postiohexol contrast computed tomography study with retrograde contrast cystogram. Urine culture confirmed the presence of a recurrent Escherichia coli urinary tract infection. The patient was managed medically, primarily as an outpatient, and had complete resolution of all problems. This case represents an extremely rare form of EC with pneumoperitoneum, without evidence of concurrent urinary bladder rupture. Only six similar cases have been reported in humans, with no previous cases reported in veterinary medicine. This case demonstrated that surgery is not necessarily indicated in all cases of pneumoperitoneum. The patient remained alive at 2 mo follow-up, with no evidence of recurrence of EC.

Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial.

BACKGROUND: Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS: Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS: Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS: Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.

[Low-pressure pneumoperitoneum with abdominal elevation in laparoscopic radical prosta-tectomy in elderly patients with a localized form of prostate cancer.]

Prostate cancer is an actual problem among males of older age groups, while the concomi-tant premorbid background of this category of patients often leads to the development of postopera-tive complications using the standard surgical method. The article presents the results of using low-pressure pneumoperitoneum with anterior abdominal wall lifting for laparoscopic radical prostatec-tomy in elderly patients with a localized form of prostate cancer. Convincingly shown that the use of low-pressure techniques pneumoperitoneum with lifting anterior abdominal wall ensures satis-factory operating field, obtains stable indicators of operational monitoring and allow to reduce the duration of the operation, as well as reduce the duration of hospitalization and incidence of postoperative complications.

Bladder pressure monitoring and CO2 gas-related adverse events during per-oral endoscopic myotomy.

Per-oral endoscopic myotomy (POEM) is a minimally invasive treatment for esophageal achalasia. However, POEM has the potential risk of inducing carbon dioxide (CO2) gas-related adverse events, such as pneumoperitoneum, pneumomediastinum, and pneumothorax. The aim of this study was to evaluate the usability of bladder pressure monitoring as an index of CO2 gas-related pneumoperitoneum. The monitoring of bladder pressure and lung compliance and the incidence of iatrogenic pneumoperitoneum were retrospectively studied in 20 patients who underwent POEM between June 2013 and March 2015. The bladder pressure was measured using a Foley catheter. Abdominal distention was found in nine patients. The bladder pressure was significantly higher in the nine patients with the distention findings compared with patients without distention [7 (6-9) mmHg vs. 1 (0-2) mmHg; P < 0.05]; however, the decrease in dynamic lung compliance was not significantly different compared with patients without distention [- 7 (- 9.3 to - 5.1) vs. - 5 (- 10.2 to - 1.3) ml/cmH2O; P = 0.62]. Based on postoperative changes on CT scans; the following were the observations: pneumomediastinum (55%), minor pneumothorax (5%), pleural effusion (45%), atelectasis (15%), pneumoperitoneum (85%), and subcutaneous emphysema (15%). No significant clinical status was found among the patients postoperatively. Bladder pressure monitoring might be useful for detecting pneumoperitoneum during POEM.

The Intensity of Postlaparoscopic Shoulder Pain Is Positively Correlated with the Amount of Residual Pneumoperitoneum.

STUDY OBJECTIVE: Residual carbon dioxide, which is inevitably retained in the abdominal cavity after laparoscopy, plays an important role in inducing postlaparoscopic shoulder pain (PLSP). The aim of this study was to determine the relationship between the volume of a residual pneumoperitoneum and the intensity of PLSP. DESIGN: A prospective cohort study (Canadian Task Force classification II-2). SETTING: A university hospital. PATIENTS: A total of 203 patients undergoing laparoscopy for nonmalignant gynecologic diseases. INTERVENTIONS: Gynecologic laparoscopy. MAIN OUTCOME MEASURES: The volume of the residual pneumoperitoneum was measured by performing chest radiography 24 hours after surgery. The pneumoperitoneum was graded as high volume (defined as ≥the median volume of the pneumoperitoneum) and low volume (defined as

Complications of CO2 insufflation during endoscopic vein harvesting.

Over the past few decades, the use of endoscopic harvest of the saphenous vein has gained popularity due to a significant reduction in rates of wound infection and improved cosmesis. The widespread adoption of this technique has introduced a set of complications associated with the use CO2 insufflation which facilitates exposure during the vein harvest. We describe a case of pneumoperitoneum with systemic acidosis and subcutaneous air following endoscopic vein harvest for coronary artery bypass grafting and review the complications that may arise from CO2 insufflation during endoscopic vein harvesting.

Air and its Sonographic Appearance: Understanding the Artifacts.

BACKGROUND: Although air has traditionally been considered a barrier to sonographic imaging, when encountered in unusual settings it can serve as an important indicator of various pathologic states as well. Clinician recognition and thorough understanding of the characteristic pattern of artifacts generated by air are critical for making a number of important diagnoses. CASE SERIES: We present five emergency department cases in which air was visualized in a pathologic location. Pneumothorax, pneumoperitoneum, necrotizing fasciitis, or Fournier's gangrene, and subcutaneous emphysema and pneumomediastinum, can be rapidly and easily identified on ultrasound by the presence of air artifacts. The relevant sonographic findings are described and discussed in this article. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to its inherent impedance mismatch with other human tissues, air has a characteristic appearance on ultrasound that includes irregular hyperechoic structures, "dirty shadowing," A-lines, and decreased visualization of deeper structures. Knowledge of the sonographic appearance of air artifacts can assist the physician in making a diagnosis, selecting appropriate additional imaging, and enlisting specialist consultation.

Emphysematous cholecystitis presenting as gas-forming liver abscess and pneumoperitoneum in a dialysis patient: a case report and review of the literature.

BACKGROUND: Emphysematous cholecystitis is a rare variant of acute cholecystitis with a high mortality rate. The combination of emphysematous cholecystitis, liver abscess and pneumoperitoneum are even rarer. Herein we present a case of emphysematous cholecystitis in a senile diabetic lady who had worsening hemodynamics while undergoing hemodialysis. CASE PRESENTATION: A 64-year-old woman with history of type 2 diabetes mellitus and end stage renal disease with regular hemodialysis presented to the emergency department with a 1-day history of sudden onset of lassitude and hypotension during hemodialysis. The result of a computed tomography (CT)-scan revealed air encircling the gallbladder, liver parenchymal and minimal pneumoperitoneal and liver abscess with no cholelithiasis. The patient had received empirical antibiotics with piperacillin-tazobactam 2.25 g intravenous route every 6 h for 14 days and cholecystectomy with surgical debridement and lead an uneventful postoperative hospital course. Escherichia coli was demonstrated as well as blood culture and peritoneal fluid culture. CONCLUSION: In a senile diabetic and dialysis patient, we should take emphysematous cholecystitis into consideration once vague abdominal pain occurrs. Empirical antibiotic therapy and adequate surgical intervention should take place as soon as possible.

Intestinal perforation in premature neonates: The need for subsequent laparotomy after placement of peritoneal drains.

AIM: In view of recent studies questioning the usefulness of peritoneal drainage (PD) in premature neonates with pneumoperitoneum, suggesting approximately 75% of those treated with PD needed delayed laparotomy, we reviewed the requirement for laparotomy after initial PD at our institution. METHODS: Retrospective cohort of all premature infants with a diagnosis of intestinal perforation (ICD Code P78.0) from 1995 to 2012. Inclusion criteria were pneumoperitoneum on x-ray (isolated perforation or necrotising enterocolitis), birthweight <1800 g and gestational age <33 weeks. RESULTS: Fifty patients met the criteria (38 PD, 12 primary laparotomy). Thirty-two per cent (95% CI 18-49%) received secondary laparotomy after initial PD. There was no significant difference when stratified according to isolated perforation (24%) versus necrotising enterocolitis (56%, P = 0.11). There was no significant difference between PD and primary laparotomy for time to full enteral nutrition, hazard ratio (HR) 0.99 (95% CI 0.48-2.04) or mortality, HR 2.15 (95% CI 0.48-9.63). The HR for mortality was partly confounded by birthweight, birthweight-adjusted HR 1.52 (95% CI 0.32-7.23). CONCLUSIONS: Thirty-two per cent of neonates treated with primary PD received secondary laparotomy, with no significant difference in key outcomes. Primary PD still appears to be of benefit for those without features of necrotising enterocolitis.

[Abdominal pain and fever with urinary symptoms]. / Douleur abdominale fébrile associée à des signes urinaires.

A man consults for abdominal pain and fever. The diagnosis is suspected on a plain abdominal radiograph.

Un homme consulte pour des douleurs abdominales et une fièvre. Le diagnostic est évoqué sur une radiographie de l'abdomen sans préparation.

A Novel Cause of Free Intraperitoneal Air in the Emergency Department.

Although all emergency physicians are familiar with catastrophic causes of free intraperitoneal air, we describe the case of a healthy 26-year-old woman who presented to our emergency department (ED) with a nonsurgical and previously unreported cause of pneumoperitoneum. The patient presented to our ED with complaints of shoulder and neck pain several hours after having undergone FemVue ultrasonography (Femasys, Suwanee, GA) for infertility evaluation. The technique uses an air and saline solution mixture injected into the uterine cavity to assess for tubal patency and uterine cavity morphology. Although the cause of her free air and pain was determined to be iatrogenic and ultimately benign, this complication is previously unreported and, without complaints of abdominal pain, presented a diagnostic challenge.

Pneumoperitoneum in in-vitro Conceived Quadruplet Neonate: Rare Manifestation of Hirschsprung's Disease--Report of a Case.

INTRODUCTION: Hirschsprung's disease is a congenital colonic aganglionosis, usually presented as inability or difficulty in passing of meconium, chronic and persistent obstipation, maleficent feeding, vomiting, distension and lethargy. CASE PRESENTATION: We presented a case of an in-vitro conceived quadruplet premature neonate who presented with pneumoperitoneum caused by transverse colon spontaneous perforation and microcolon appearance of distal bowel, treated by resection and temporary colostomy turns to be a rare manifestation of Hirschsprung's disease. CONCLUSION: Assisted reproductive technologies increases chances for multiple pregnancies and may increase chance for major congenital anomalies. Rare manifestation of Hirschsprung's disease is spontaneous pneumoperitoneum which remains a surgical emergency. Delay in recognizing and treatment can significantly worsen prognosis. In neonate with intestinal perforation one should consider Hirschsprung's disease.

Early diagnosis of pneumoperitoneum in bowel perforation by capnography: a report of 2 cases.

Capnography is commonly used for monitoring purposes. Here, we describe a new application of capnography as a bedside diagnostic modality. In doubtful situations of pneumoperitoneum, intravenous cannula is inserted in abdominal cavity, and capnography wave forms are detected with the help of gas sampling port. Capnography can detect pneumoperitoneum of bowel origin quickly and efficiently when radiology and clinical diagnosis are inconclusive. It can also detect gas in supine position. This technique is useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum.