Images in Clinical Medicine

Pneumoperitoneum

Jonathan Ailon, M.D.

N Engl J Med 2012; 366:e26April 26, 2012DOI: 10.1056/NEJMicm1112622

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A 69-year-old woman presented to the emergency department with a 3-day history of progressively worsening abdominal distention and pain. She was taking dexamethasone for cerebral edema associated with glioblastoma multiforme. She had not received antiangiogenic therapy during her treatment course. The patient was cachectic and had rapid, shallow respirations. Abdominal examination revealed notable distention, tympany, and voluntary guarding but no rebound or overt signs of peritonitis. Plain-film radiographs of the chest obtained with the patient in the frontal and lateral positions revealed evidence of pneumoperitoneum, with gas extending from the infradiaphragmatic region to the inferior margin of the liver, outlining the gallbladder (Panel A, arrow). Gas outlined the spleen on the lateral view (Panel B, asterisk). The findings were highly suggestive of bowel perforation. The decision was made to pursue comfort care, in accordance with the patient's stated goals. A bedside venting procedure was performed to decompress the abdomen and provide symptomatic relief. The patient died shortly thereafter.

Jonathan Ailon, M.D.
University of Toronto, Toronto, ON, Canada
jonathan.ailon@utoronto.ca

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