Pneumoperitoneum as a result of a ruptured splenic abscess
A 48-year-old female with the past medical history of diabetes, coronary artery disease and psoriasis, presented with acute onset of diffuse abdominal pain 2 days prior to admission to the hospital. Upon presentation, she was tachycardic with a heart rate of 130 and hypotensive with a blood pressure of 78/45. The patient was afebrile and alert and oriented to person, place and time. She was resuscitated in the emergency department with intravenous fluids and her blood pressure and heart rate responded appropriately.\nHer initial labs showed a normal WBC level of 8.3 thou/mcL; however, the patient was acidotic with a pH of 7.29 and a lactic acid level of 3.5 mmol/l. An acute abdominal series was obtained demonstrating free air below the right hemidiaphragm (Fig. ). Physical examination showed a distended abdomen with tenderness, guarding and signs of peritonitis. The patient was subsequently boarded for an exploratory laparotomy with repair of perforated viscus, as that is the usual cause of pneumoperitoneum, especially under the right hemidiaphragm. Because the patient's vital signs stabilized after being resuscitated, the decision was made to obtain a CT scan to better assess the location of the perforated viscus. Much to our surprise, the patient did not have a perforated viscus, but a splenic abscess that had ruptured causing the pneumoperitoneum (Fig. ).\nThe patient then became increasingly confused and her vital signs again deteriorated demonstrating worsening sepsis. The patient was taken to the operating room where a laparoscopic splenectomy was attempted but was quickly converted to laparotomy with splenectomy due to the gross contamination of the abdomen. The abdominal compartment was copiously irrigated and the abdomen was closed. The surgery was without any complications. The patient was continued on antibiotics and taken to the intensive care unit for post-operative care.\nThe patient did well post-operatively. The splenic abscess grew Prevotella intermedia, a bacterium commonly found in the oral flora. Her blood cultures were negative. The patient underwent a full work-up looking for the source of the splenic abscess. A transesophageal echocardiogram was performed but was negative for any masses, thrombus or vegetation. Furthermore, a panorex was performed and was negative as the patient had reported tooth pain 1 week prior to her admission. The patient was finally deemed stable for discharge on post-operative day 10. She returned to the clinic on post-operative day 14 to receive her splenectomy vaccinations.