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Highlights • Pneumoperitoneum may not always be an ominous sign in the pediatric population. • Cases of non-surgical pneumoperitoneum in the pediatric population are scarce. • The clinical picture of a patient should be the primary determinant of management. • Conservative measures can be used in pediatrics with isolated pneumoperitoneum. • If the diagnosis is still unclear, clinical correlation should take precedence., Introduction Pneumoperitoneum frequently results in emergent surgery because it typically indicates an abdominal viscus perforation. However, this may not always be the case. There have been few recent reports in the pediatric population that document cases of pneumoperitoneum which could be considered for non-surgical management. Presentation of case This case series presents three different instances of pediatric patients with radiographic evidence of pneumoperitoneum who were subsequently found to have no perforated viscus following surgical intervention. Conclusion We recommend that in the absence of peritoneal signs, fever, leukocytosis, significant abdominal pain, distension, or clinical deterioration, non-operative management be considered in pediatric patients with radiographic signs of pneumoperitoneum.

Evisceration of abdominal viscus following “Flowerpot firecracker” (tubri) blast injury to the abdomen is a rare but dangerous form of domestic accident. Lack of knowledge and non-compliance of safety measures is the major reason for firecracker eventualities. A 10-year male child presented three hours post-injury with a wound over the upper abdomen. On examination there was evisceration of part of stomach along with colon through supraumbilical abdominal wound. Resuscitation and repair following exploratory laparotomy performed. Patient recovered well postoperatively. Public awareness and safety measures need to be taken to prevent the fatal outcomes of firecracker misuse.

Anamnese und klinischer Befund: Ein 19-jahriger Patient mit Muskeldystrophie Duchenne wurde wegen eines bronchopulmonalen Infekts stationar aufgenommen. 4 Monate zuvor war bei ventilatorischer Insuffizienz eine nichtinvasive Heimbeatmung eingeleitet und aktuell nur nachts angewendet worden. Zum Zeitpunkt der Aufnahme war bei atemmuskularer Erschopfung keine langerfristige Spontanatmung moglich. Der Patient zeigte sich fiebernd mit ausgepragter Ruhedyspnoe und einem unzureichenden Hustenstos. Das Abdomen war auffallend geblaht ohne Abwehrspannung. Untersuchungen: Blutgasanalytisch bestand auch unter nichtinvasiver Beatmung eine respiratorische Azidose. Laborchemisch zeigten sich erhohte Entzundungsparameter. Radiologisch fielen hochstehende Zwerchfelle auf, ein pneumonisches Infiltrat demaskierte sich wenige Tage spater links basal. Unter fast durchgehender nichtinvasiver Beatmung konnten bald Normokapnie und ein Ausgleich der Azidose erreicht werden. Die Spontanatmungsintervalle nahmen zu. Im Verlauf der nachsten Tage fiel ein Hautemphysem auf, radiologisch fand sich am 9.Tag nach Aufnahme erstmalig bilateral freie abdominelle Luft. Therapie und Verlauf: Der radiologische Befund bestatigte sich in weiteren Kontrollen, zeigte kein klinisches Korrelat und die Infektparameter waren rucklaufig. Nachdem der Infekt sich besserte und die Beatmung reduziert werden konnte, bildete sich die subphrenische Luft vollstandig zuruck. Folgerung: Der Nachweis freier abdomineller Luft bei diesbezuglich unauffalliger Klinik muss nicht zwingend zur operativen Exploration fuhren. Unter engmaschiger Verlaufskontrolle kann, wenn wie in diesem Fall eine Ursache fur die Luftunterkupplung abdominell (langerfristige Maskenbeatmung mit hohen Beatmungsdrucken) vermutet wird, ein abwartendes Verhalten empfohlen werden. Eine Erklarung fur die freie Luft kann ein durch den erhohten intrathorakalen Druck bedingtes interstitielles Emphysem mit konsekutivem Luftdurchtritt durch eine Zwerchfelllucke sein.

Laparoscopic-adjustable gastric band (LAGB) complications are increasingly recognised as follow-up time increases. These are most commonly related to the gastric band or port site, but complications of the connecting tubing are also reported. We present a case of LAGB tubing penetration through the transverse colon causing abdominal sepsis in a complex surgical abdomen and review prior published cases of abdominal viscus penetration by LAGB tubing. Like complications involving all LAGB components, these often present with non-specific abdominal signs and symptoms and undergo abdominal CT as an early investigation. This makes knowledge of normal and pathological imaging features of LAGB components important in radiology practice.

Gunshot wounds to the pelvis can result in injuries to various organ systems. These injuries require the care of a multispecialty trauma team at a trauma center. Orthopaedic care includes wound treatment, fracture stabilization, and infection prophylaxis. Wound care is determined by the personality of the injury, and not solely based on the velocity of the missile. Antibiotic treatment usually is indicated for patients with gunshot wounds to the pelvis, but is controversial in patients with low-energy wounds. Fractures are treated based on their stability. Regional consideration of pelvic gunshot wounds includes injuries with associated abdominal viscus injury, intraarticular bullets, and retained bullets in the spinal canal.

Acute abdominal pain is a common presentation to the ED. Most patients undergo a chest radiograph as part of their initial investigations, which occasionally reveals pneumoperitoneum. Pneumoperitoneum on imaging suggests a perforated hollow abdominal viscus and therefore often constitutes a surgical emergency. However, if the patient is neither peritonitic nor septic a management dilemma is faced. Some cases of pneumoperitoneum might be managed conservatively thus avoiding unnecessary laparotomy. We present a case of recurrent spontaneous pneumoperitoneum with abdominal pain that was managed conservatively and discuss the possible aetiologies and management issues of spontaneous pneumoperitoneum.

Pneumoperitoneum frequently indicates a perforated abdominal viscus that requires emergent surgical management. However; pneumoperitoneum, on rare occasion, can occur without perforation. In these cases, it is defined as benign pneumoperitoneum. Benign pneumoperitoneum means asymptomatic free intra-abdominal air or pneumoperitoneum without peritonitis and can occur occasionally with colonoscopy. In this paper, we present a rare case of benign pneumoperitoneum that developed after diagnostic colonoscopy and review it in conjunction with the current literature.

Pneumoperitoneum is considered to be a surgical emergency as it nearly always indicates a perforated abdominal viscus. However, in rare cases, the presence of ‘free gas under diaphragm’ may not imply the need for emergent laparotomy, as pneumoperitoneum can occur without any gastrointestinal leakage. Here we report a rare case of a previously healthy boy with pneumoperitoneum associated with pneumonia and perform a review of the literature to explore the etiological mechanisms and the pathophysiology of non-surgical pneumoperitoneum.

The finding of intraperitoneal free gas usually indicates a perforated abdominal viscus, and requires emergency surgery. In a minority of cases, no perforation can be found, a situation that can be classified as “spontaneous” pneumoperitoneum. A conservative approach may be considered if clinical signs are minimal, particularly when peritoneal signs, fever and leucocytosis are absent. The various causes of spontaneous pneumoperitoneum are discussed.

Penetrating abdominal injury resulting from home accidents is rare. Only one such case was found in the English literature after online searching on PubMed. We report two cases of penetrating abdominal injury. The first was a 2-year-old girl who was brought into the emergency room (ER) with evisceration of most of the stomach through the left hypochondrium. She had fallen on a broken soft drink bottle; she was holding, after missing her steps. On examination, she had a penetrating injury in the left hypochondrium and a 1.5 cm perforation on the proximal aspect of the anterior wall of the stomach. She was explored within 3 h of presentation, during which the gastric perforation was closed eviscerated bowel returned into the peritoneum and primary wound closure achieved. The patient did well postoperatively. The second was a 9-month-old boy who was brought to the ER by parents on account of gut evisceration following injury from a soft drink bottle at home. He sustained injury from exploded soft drink bottle while crawling. Examination revealed a penetrating injury in the left upper quadrant with evisceration of small intestinal loops. He also had exploratory laparotomy within 4 h of presentation, during which intact abdominal viscera was found. Bowel loops were returned and primary abdominal closure done. Postoperatively, the patient did well. These cases are eye openers to an unusual form of domestic injury, exemplifying the potential hazards of soft drink bottles in the home. Awareness about this is pertinent.

There is clear evidence that booster seats reduce motor vehicle-related injuries among children four to eight years of age (1,2). Despite this fact, booster seats are currently underused in this population. Evidence from controlled studies shows that a variety of interventions will increase parental use of booster seats. Interventions that include more than one tactic (ie, a combination of education and incentives, or a combination of education and distribution of a free booster seat) may be the most effective. The Canadian Paediatric Society recommends that children weighing between 18 kg and 36 kg (between 40 lbs and 80 lbs), and having a height of less than 145 cm (57 inches), or are eight years of age or younger, should use a booster seat and be placed in the back seat of a vehicle (3). Booster seats improve seat belt fit among children by elevating them off the seat and allowing the seat belt to lie across the pelvis, and ribcage and shoulder, rather than the stomach and neck. Abdominal viscus injury, abdominal bruising and fractured vertebrae, that occur among children not using a booster seat, are collectively known as ‘lap-belt syndrome’, and refer to any injury in which the improperly fitting seat belt has actually injured the child in lieu of protecting him or her (4). Among children, nonuse and misuse of age-appropriate child restraints are common factors associated with motor vehicle-related morbidity and mortality (5). Booster seats can reduce the risk of injury in a motor vehicle collision by up to 59% (6). Compared with children who are appropriately restrained in booster seats, those restrained by a seat belt alone are at 3.5 times the risk of injury and 4.2 times the risk of head trauma (7,8). A study (9) between 1998 and 2002, examining motor vehicle collisions involving children four to seven years of age from Wisconsin, USA, showed that 16 of the 28 observed deaths, and 84 of the 144 hospitalizations would have been prevented if the children were using booster seats at the time of the collisions (9). While similar statistics are not available for Canada, self-reported booster seat use among Canadians was found to be 28% (10); approximately 400 Canadian children are killed or hospitalized with a serious injury each year due to a motor vehicle collision (unpublished data). Between 1994 and 2000, hospital admissions have decreased by 40% to 50% among children zero to four years of age, and 10 to 14 years of age, but only declined by 18% in children five to nine years of age (unpublished data). Current research demonstrates that the prevalence of booster seat use is low. Often, children are incorrectly placed in a seat belt when they are too young. In 1997, Decina and Knoebel (11) found that 75% of preschool-aged children were restrained only by a seat belt. Winston et al (12) examined four years of restraint patterns among children younger than nine years of age who were in a collision in one of 15 American states. Between 1998 and 2002, the use of booster seats increased from 3.8% to 8.9% among children four to eight years of age. Among children four to eight years of age from Michigan, USA, only 194 of 3420 children were restrained in a booster seat and 1255 children were unrestrained (5). The age of the driver and his or her own seat belt were the strongest predictors of booster seat use. When asked about booster seat use among their four- to eight-year-old children, parents in Michigan stated that their primary motivation to use booster seats was safety (13). Reasons for nonuse included lack of enforcement, perceived inconvenience, refusal by the child, parents believed that their child was too big and lack of knowledge regarding the safety benefits derived from using a booster seat. Parents reported that mandatory booster seat legislation would increase the likelihood of booster seat use. Simpson et al (14) conducted focus groups in an effort to determine strategies to increase booster seat use. Parents identified media campaigns, legislation, education and the requirement of older children to use restraints as potential methods to increase booster seat use (14).

Two patients who sustained severe blunt injury to the pelvis without external injury to the upper abdomen or lower chest, yet who were found to have a ruptured solid upper abdominal viscus, are reported. The first patient on delayed arrival revealed clinical features suggestive of intra-abdominal bleeding and was found to have a grade 3 ruptured spleen. With the second patient, upper abdominal injury (in this instance, a pancreatic laceration) was not initially suspected owing to the absence of clinical evidence of injury to the abdomen. It is postulated that both the splenic and pancreatic injuries were the result of a shockwave propagated through the abdomen following the severe external impact to the pelvis.

The presence of free gas under one or both hemidiaphragms on an erect chest x-ray is most frequently the result of recent abdominal surgery or, in the absence of such surgery, is almost always indicative of a perforated abdominal viscus. A case is reported of a patient in whom pneumoperitoneum was discovered incidentally on a chest x-ray following extensive pelvic manipulation for acute inversion of the uterus.

A short cut review was carried out to establish whether a normal erect chest radiograph excludes the diagnosis of perforated abdominal viscus. Altogether 37 papers were found using the reported search, of which two presented the best evidence to answer the clinical question.. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 1. A clinical bottom line is stated.

A detailed analysis was made of the complications of peritoneal dialysis encountered during 184 dialyses performed in 107 severely ill patients at two teaching hospitals where the major responsibility for the dialysis rests outside a specialized renal unit. Only 9.8% of the dialyses were done to maintain patients for renal transplantation, and no chronic maintenance peritoneal dialyses were performed. Significant mechanical, infectious, cardiovascular, pulmonary, neurologic and metabolic complications occurred in 68% of the dialyses. Dialysis related peritonitis occurred in 6.3% of the dialyses and no instance of perforation of an abdominal viscus occurred. In spite of the high incidence of complications 75% of the dialyses produced significant improvement in the clinical status of the patient. In 32% of the dialyses no or only minimal complications were encountered. Death occurred in 20 patients and was assumed to have been a direct result of the dialysis in 7 or 6.5%. It is apparent that this assumedly safe procedure carries a considerable risk. However, increased knowledge of the mechanics and hazards of peritoneal dialysis, close patient observation and meticulous attention to apparently small details, should decrease the number of complications and preserve the effectiveness of the procedure.

The lesson of this column is: In an emergency, treat first and ask legal questions later. This is both good medicine and good law.There is no universally recognized definition of an emergency, and the law will generally accept the determination of health care professionals, if consistent with accepted practice, in defining an emergency condition or situation. The most common definition is that an emergency is any injury or acute medical condition liable to cause death, disability, or serious illness if not immediately attended to.Obvious examples of emergency conditions that require theimmediateattention of a physician or properly trained health professionalto prevent loss of lifeinclude:Massive hemorrhage from major vesselsCardiac arrestCessation or acute embarrassment of respirationProfound shock from any causeRapidly acting poisonAnaphylactic reactionsAcute epidural hemorrhageAcute overwhelming bacteremia andtoxemiaSevere head injuriesPenetrating wound of the pleura or pericardiumRupture of an abdominal viscusAcute psychotic states.

Twelve patients with splenic abscesses encountered at The New York Hospital-Cornell Medical Center between 1932 and 1960 are presented. Data concerning age, sex distribution, underlying disease processes, bacteriologic studies and autopsy observations are presented. Ninety-one and seven-tenths per cent (91.7 per cent) of the abscesses were thought to result from blood stream infection, so-called “metastatic abscesses” and 8.3 per cent from perforation of an adjacent abdominal viscus. The presence of coexisting serious illness and the questionable value of operation are stressed.

Roentgenographic illustration of complications with the use of neonatal umbilical vascular catheterization is presented.Examples of air and catheter embolic phenomena, arterial and venous thrombosis, perforations of abdominal viscus, and hepatic necrosis are illustrated.

THE determination of the presence, size, shape, position, and origin of a mass in the abdomen is a problem which has always intrigued medical men. While in some cases the answers to these questions may be readily obtainable from the history and physical findings, frequently these methods alone are insufficient. Hardly a more difficult task faces the clinician than that of deciding whether or not he feels an abnormal mass and, if so, whether it is intraor retroperitoneal in situation, pelvic or upper abdominal in origin, and to which organ it is attached. This diagnostic problem, no doubt, led to the discovery and use of pneumoperitoneum in roentgen diagnosis. It has led to many other methods of rendering an abdominal viscus or mass visible by the use of contrast media. The roentgen visualization of the gastro-intestinal tract, the urinary tract, the gall bladder, the uterus and tubes, and now the liver and spleen have all been steps in the advancement of the diagnosis of abdominal masses. The most recent ...

This case is presented as an unusual instance of a huge gas-containing abdominal viscus. The patient was a 75-year-old, non-diabetic male, whose initial complaint was haematuria. Because of marked abdominal distension and moderate discomfort he was admitted to the hospital, whereupon radiographs demonstrated the cause of the distension.

Massive pneumoperitoneum developing immediately following initiation of artificial ventilation is an unusual sign of pulmonary barotrauma, and must be distinguished from pneumoperitoneum following rupture of a hollow abdominal viscus. We present a case of massive pneumoperitoneum and scrotal pneumatocele which we attributed to pulmonary barotrauma after excluding other causes. Awareness of this entity will enable early diagnosis and avoid unnecessary laparotomy.

Two cases are reported in which the question of diagnosis was of extreme and immediate importance and in which the treatment of the conditions considered were entirely and radically different. The use of a simple procedure such as abdominal puncture yielded the necessary information in the shortest possible time.

• Pneumoperitoneum is not invariably associated with ruptured or perforated intra-abdominal viscus. To determine the incidence of free air associated with intra-abdominal viscus perforation, the medical records of 77 consecutive patients whose discharge or autopsy diagnosis included pneumoperitoneum or perforated viscus at a community hospital were retrospectively reviewed between June 1980 and October 1985. Abdominal viscus perforation, as determined by contrast studies or at operation, was not invariably associated with free air. Sixty-nine percent (23/33) of gastroduodenal, 30% (3/10) of small-bowel, and 37% (11/30) of large-bowel perforations had free air, as determined by preoperative x-ray film. Four cases with a total of six episodes of pneumoperitoneum were identified where viscus perforation was not documented. Pneumoperitoneum thus remains a reliable sign of viscus perforation; however, lack of this finding does not rule out perforation, and unusual causes must be considered. ( Arch Surg 1988;123:709-712)

Torulopsis glabrata peritonitis occurred in a patient after surgery for a ruptured abdominal viscus. The infection was successfully treated with intraperitoneal amphotericin B alone. Pharmacokinetic information regarding the distribution and clearance of amphotericin B administered by this route is presented, and the clinical manifestations and treatment modalities for T glabrata and Candida peritonitis are reviewed. ( JAMA 1983;249:1187-1188)

The complications of whooping cough are numerous and varied. Rarely, however, does the rupture of an abdominal viscus occur during this disease as the result of severe coughing. The following case is an illustration of this unique complication. REPORT OF CASE History. —In consultation with Dr. Charles A. James, I saw a poorly nourished girl, 2 years of age, in the third week of an attack of whooping cough. Two days previously she had an unusually severe attack of coughing which terminated in a convulsion. Following the convulsion the child remained pale, weak and restless. The temperature of the outside atmosphere at this time, midsummer, reached a daily maximum of about 110 F. (43.3 C.). This fact was significant, because fluids given by mouth were not retained, and the child became dehydrated and presented the symptoms of high intestinal or pyloric obstruction. The temperature rose to 105 F. (40.5 C.).

To the Editor .—We chose peritoneal dialysis as the treatment for this patient because we considered it safer, simpler, and more efficacious than exchange transfusion as a treatment for acute renal failure. The mortality rate associated with exchange transfusion is known, but much less information is available on the morbidity and mortality of peritoneal dialysis. A recent article ( Lancet 1 : 64 [Jan 13] 1968) summarizes the complications when 443 intraperitoneal catheters were inserted. An abdominal viscus was perforated six times and intra-abdominal hemorrhage occurred twice. There were three deaths. The authors recommend, and we agree, that the technique of filling the abdomen via a large-bore needle prior to catheter insertion should reduce these complications.

The sacs of inguinal hernias have been known to contain almost every type of normal and diseased abdominal viscus. Malignant tumors of organs contained in the sacs have been described, and, less frequently, secondary involvement of the tissues of the sac by extension or metastasis has been noted. Primary malignant tumors of the tissues of hernial sacs, however, are extremely infrequent. Baretz 1 reported an adenocarcinoma of a hernial sac, but it is obvious that a tumor of this type could not have arisen primarily from any but an epithelial structure and could not, therefore, have been primary in the sac. Unfortunately, postmortem examination was not done. Pagliani 2 reported a benign tumor, a fibromyxoma, which was primarily in the sac and which had been diagnosed preoperatively as a strangulated hernia. The only case encountered in the literature of the past two decades of primary malignant tumor of the sac