Spontaneous idiopathic recurrent pneumoperitoneum
In 2011, a 46-year-old man presented with an acute abdomen. Patient had a 3 day history of abdominal pain with dyspepsia, initially epigastric with pain radiating to his shoulder. He had no associated symptoms of nausea, vomiting or change in bowel habit. There was no history of peptic ulcer disease, inflammatory bowel disease, diverticular disease or malignancy. His pain was refractory to standard analgesics and exacerbated by movement and palpation of the abdomen. There was no past medical or family history of note, and the patient had never experienced these symptoms before. Routine observations were normal, except for tachycardia. On examination, there were no peripheral stigmata of inflammatory bowel disease, abdomen was diffusely tender and tympanic, but soft with normal bowel sounds. Blood tests showed no significant abnormalities, and C-reactive protein (CRP) levels were not measured. Plain abdominal and erect chest radiographs showed pneumoperitoneum (Fig. ) with Rigler's sign present around small bowel loops lower in the abdomen (Fig. ).\nHe was taken for urgent laparotomy to evacuate the free gas and aid diagnosis. The bowel was extensively examined and no evidence of perforation was found. The abdominal wall was closed and he returned to the ward. Subsequent X-rays showed that the pneumoperitoneum had resolved. Post-operatively his CRP level was 226 and he went into ileus requiring nasogastric tube placement (Fig. ). With recurrence of normal bowel activity and with settling of his symptoms, he was discharged.\nOver a year later, the same gentlemen presented to the surgical admissions unit once again with a history of acute abdominal pain. The duration and nature of symptoms were very similar to his previous admission. He again underwent plain film abdomen and erect chest radiographs that showed a large volume of free air under the diaphragm (Figs. and ).\nThe patient was apyrexial and cardiovascularly stable, other than his acute abdominal pain, he was healthy. We managed his pain with analgesia, stepping up as required. A water soluble contrast study was arranged, this demonstrated no leak or diverticular in the oesophagus, stomach or duodenum.\nHe underwent a computed tomography (CT) scan of his chest/abdomen and pelvis, and this showed some upper abdominal fluid, some small sigmoid diverticulae but nil else. The scan was discussed at a regional radiology meeting to look for any diaphragmatic defects or any other cause of pneumoperitoneum, but none were found.\nThis man demonstrated clear pneumoperitoneum, he was extensively investigated; all blood tests were normal except for a raised postoperative CRP, his laparotomy showed no evidence of perforation, the contrast study showed no leak and a CT scan showed mild sigmoid diverticulae only. In light of all this, we reached a diagnosis of ‘Recurrent spontaneous idiopathic pneumoperitoneum’.