Article Title

Massive Pneumoperitoneum



A 72-year-old man with a past medical history of pancreatic adenocarcinoma status post biliary and duodenal stent placement presented to the emergency department for one week of cramping abdominal pain in the setting of a surveillance abdominal/pelvis computed tomography (CT) scan done two days prior to admission that showed massive pneumoperitoneum (Figure 1). The patient felt bloated but otherwise had no complaints on presentation. His physical exam was significant for marked abdominal distension with mild diffuse tenderness on palpation, normal bowel sounds, and no peritoneal findings of guarding or rebound. Given concern for perforated viscus causing pneumoperitoneum, he was started on intravenous antibiotics and antifungal therapy. Repeat CT scan on admission demonstrated patent biliary and duodenal stents and no definite source of perforation. The patient remained hemodynamically stable throughout his hospitalization; he continued to have regular bowel movements daily and eventually tolerated a diet. His abdominal distension and pain gradually improved without any surgical intervention, and he was discharged home six days after admission to complete 7 days of oral fluconazole, levofloxacin, and metronidazole. It was thought that this patient most likely had a perforated viscus that sealed off. A CT scan two months later showed complete resolution of the pneumoperitoneum.