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Pneumoperitoneum - Causes, Symptoms, Diagnosis, and Treatment

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Pneumoperitoneum is gas or air entrapment in the peritoneal cavity. Read this article to know more.

Medically reviewed by

Dr. Ghulam Fareed

Published At February 22, 2023
Reviewed AtFebruary 27, 2024

What Is the Peritoneal Cavity?

The space between the parietal and visceral peritoneum is called the peritoneal cavity. The parietal and visceral layers line the peritoneal cavity, and this lining attaches and protects the vital organs. The structures bound by the peritoneal cavity are called retroperitoneal and intraperitoneal.

Boundaries of the peritoneal cavity are as follows:

  • Vertebrae.

  • Pelvic floor.

  • Diaphragm.

The peritoneal cavity is further divided into the greater and lesser peritoneal cavities. The peritoneal cavity differs in both sexes due to different pelvic organs. The chances of the peritoneal cavity being infected are rare due to mucous plugs at the external opening. Still, the entrapment of the air or excessive fluid in the peritoneal cavity is most common.

What Is Pneumoperitoneum?

Pneumoperitoneum is a medical term used to describe the presence of free air in the abdomen or air in the peritoneal cavity, which is a space within the abdominal cavity. The most common cause of this condition is the rupture or discontinuation of the abdominal lining. This can be due to post-surgical complications or due to some other nonsurgical causes.

In cases where the cause is unknown or differs from abdominal lining discontinuation, such conditions are spontaneous pneumoperitoneum. Pneumoperitoneum can also result even when the peritoneal lining is intact. Some cases include introducing air into the peritoneum through the female vagina. It is commonly observed after intercourse. It has been observed that not every case of bowel perforation leads to pneumoperitoneum. Some of the perforations are insignificant and heal on their own. Abdominal surgeries in almost every case present with postoperative pneumoperitoneum, but this condition heals within three to four days.

What Are the Causes of Pneumoperitoneum?

The potential causes of pneumoperitoneum can be listed as follows:

  • Perforated duodenal ulcer.

  • Perforated peptic ulcer.

  • Ruptured diverticulum (the pouch that lines the digestive system gets ruptured).

  • Necrotizing enterocolitis (gastrointestinal disease affecting neonates).

  • Malignancy.

  • Ischemic bowel (intestinal disorder).

  • Laparotomy (abdominal surgical procedure).

  • Laparoscopy (diagnostic test of the abdomen).

  • Post-endoscopic bowel trauma (abdominal trauma).

  • Peritoneal infections (infection of the abdominal lining).

  • Bronchopleural fistula (the infectious connection between the bronchial tree and pleural space).

  • Vaginal insufflation (vaginal infection).

  • Vaginal douching (intravaginal cleansing).

  • Postpolypectomy syndrome (abdomen infection).

  • Severe coughing.

The above-listed causes can be divided into surgical and nonsurgical causes based on the etiology of the disease.

What Are the Signs and Symptoms of Pneumoperitoneum?

The most common signs and symptoms presented by the patients are as follows:

  • Abdominal pain.

  • Vomiting.

  • Abdominal distension.

  • Constipation or diarrhea.

  • Tachycardia.

  • Fever.

  • Hypotension.

Some of the symptoms differ according to the site of perforation, for example:

  • Duodenal Ulcer Perforation: The pain in patients with perforation is in the epigastric region and lasts for a concise duration, but the abdomen is tender on palpation.

  • Appendicular Perforation: In such cases, the patients have a classical presentation with pain originating in the periumbilical region and episodes of vomiting and fever. On examination, the guardian is noted.

  • Small Bowel Perforation: These patients have a history of fever and chronic pain in the lower abdomen. This different site of origin and pain location helps diagnose the condition and provide appropriate treatment.

How Is Pneumoperitoneum Diagnosed?

The pneumoperitoneum can be diagnosed radiographically as the gas entrapment is noted as a radiolucent patch on the radiograph. Conventional X-rays help diagnose the condition but have been reported to be misdiagnosed in cases where the amount of gas enclosed is less; therefore, computed tomography is used and considered a standard diagnostic method.

To confirm diagnosis following signs are noted on the radiographs, and the severity and the presence of the disease are confirmed based on the diagnostic criteria, which are also called diagnostic signs and are as follows:

  • Saddlebag or Mustache Sign: When the air or gas is noted in the midline or below the central tendon, radiographs taken in the supine position are termed a saddlebag sign.

  • Rigler's sign: Cases in which the air is noted to outline both sides of the bowel wall are termed the Rigler sign.

  • Lucent Liver Sign: It is observed when the liver loses its radiopacity due to the accumulation of air anterior to the liver.

  • Football Sign: When the abdominal cavity is filled by gas is termed a football sign and is observed in cases with large pneumoperitoneum, it is most commonly seen in children with iatrogenic gastric perforations and Hirschsprung's disease.

  • Silvers Sign or Falciform Ligament Sign: This is observed when the gas surrounds the Falciform ligament.

What Is the Differential Diagnosis for Pneumoperitoneum?

Some other disorders or radiographic errors can present as pseudo pneumoperitoneum.

Some of such conditions are as follows:

  • Subphrenic abscess (infection surrounding the diaphragm).

  • Chilaiditi syndrome, where the bowel is compressed between the diaphragm and liver.

  • Atelectasis (lung collapse) at the base of the lung can cause radiographic artifacts.

  • Connective tissue disorders.

  • Acute appendicitis (inflammation of the appendix).

  • Intraabdominal abscess.

  • Inflammatory bowel disease (chronic intestine inflammation).

What Is the Use of Pneumoperitoneum in Medicine?

The pneumoperitoneum is created before laparoscopic surgeries, which is one of the essential diagnostic methods in many critical patients to visualize adequately and carry out operative manipulations if required. This procedure is carried out using carbon dioxide gas as it is highly diffusible and has a rapid rate of absorption and excretion; these properties of carbon dioxide reduce postoperative complications making it safe to use. Laparoscopy is less invasive and is preferred over other surgical diagnostic procedures.

How Is Pneumoperitoneum Treated?

Pneumoperitoneum can be treated based on its underlying cause. Gastrointestinal perforation is considered one of the most common surgical emergencies and requires immediate medical attention. Some cases of pneumoperitoneum, like post-laparoscopic pneumoperitoneum, heal independently within seven to ten days.

Some of the most common treatment modalities include:

  • Surgery for the repair of the perforations.

  • Antibiotic therapy.

  • Pain relieving medications.

  • Lifestyle and food habit modifications.

  • Adequate rest.


Pneumoperitoneum is a condition in which there is free accumulation of air in the abdomen. The most probable cause of pneumoperitoneum is the breach in the continuity of the peritoneal lining. Other causes include air inclusion through the vaginal opening in females after sexual intercourse, which is diagnosed radiographically with the help of ultrasound, X-ray, or computed tomography. In some cases, pneumoperitoneum is also caused by postoperative abdominal surgeries but is cured on its own within three to four days. Still, some conditions are more severe and require medical attention, surgery, or treatment with antibiotics.

Frequently Asked Questions


Can Pneumoperitoneum Be Life-Threatening?

Pneumoperitoneum is a life-threatening condition that requires timely intervention. Point-of-care ultrasound (emergency ultrasound)  is used for timely diagnosis and planning of surgery. The condition can lead to the development of end-organ dysfunction due to septic shock.


Which Gas Is Frequently Used for Pneumoperitoneum?

Carbon dioxide is the most frequently used gas for pneumoperitoneum management. Carbon dioxide has a high diffusion coefficient and is the natural end product of metabolic activity. Therefore, can be cleared effectively from the body. Carbon dioxide does not support combustion and is highly soluble in tissues. The risk of embolism is low with carbon dioxide.


Which Organ Is Associated With Pneumoperitoneum?

Pneumoperitoneum is a condition where air accumulates in the abdominal cavity. The most frequently affected organ is the intestine or bowel. Intestinal perforation may develop due to surgical factors. Bowel perforation develops due to infection, trauma, or ulceration.


What Is the Complication That Can Develop Due to Pneumoperitoneum?

Traumatic complications that can develop due to pneumoperitoneum are visceral injury, major vascular injury, and bleeding from the abdominal wall. Respiratory complications of pneumothorax (collapsed lung), subcutaneous emphysema (air accumulating under the skin), and pneumomediastinum (air accumulating in space between two lungs) may develop. Few patients develop cardiovascular complications of increased heart, rate, blood pressure, and arrhythmia (improper heartbeat).


Can Pneumoperitoneum Be Treated?

The treatment of pneumoperitoneum includes observation, antibiotics, and emergency surgery to repair the lumen. Lifestyle and dietary changes can also help patients to recover from pneumoperitoneum. A Conservative approach can cure the disease. Surgery must not be performed until absolutely necessary.


Can Pneumoperitoneum Go Away on Its Own?

Pneumoperitoneum that develops after abdominal endoscopy or surgery does not require any treatment. The condition resolves on its own after a few weeks. Although most cases are resolved within 3 to 6 days. If the pneumoperitoneum persists medical or surgical interventions are required.


What Is the Surgical Approach for Treating Pneumoperitoneum?

Laparoscopic surgery is performed by placing an insufflation needle intrabdominal followed by carbon dioxide insufflation of the abdominal cavity at a pressure of 12 to 15 mm Hg (millimeter of mercury). Cabron dioxide is the most preferred gas for the treatment of pneumoperitoneum. Alternative gases like oxygen and nitrogen may also be used.


Can Pneumoperitoneum Cause Pain?

Depending on disease severity the affected individuals may experience localized abdominal pain to severe abdominal pain with rebound and guarding (indication of acute abdomen). In a few patients, phrenic nerve irritation caused by pneumoperitoneum may induce referred pain in the shoulder.


Is Post-surgery Pneumoperitoneum Common?

The occurrence of pneumoperitoneum following abdominal surgery is common. The pneumoperitoneum can be seen with computed tomography up to three weeks after surgery. Most cases of pneumoperitoneum were benign and resolved on their own but few required surgical interventions.


Can Pneumoperitoneum Occur Due to COVID?

Mechanical ventilation is a common cause of developing thoracic pneumoperitoneum. Therefore, COVID patients requiring high ventilation may develop pneumoperitoneum. However, pneumoperitoneum is a rare complication of COVID. They may occur due to pneumomediastinum progression or bowel perforation.


Which Instrument Is Used for Pneumoperitoneum During Laparoscopy?

Special instruments like the Hasson cannula are used in laparoscopic surgery to prevent gas leakage. Alternatively, a Veress needle may be used to establish pneumoperitoneum prior to cannula insertion in laparoscopic procedures. The telescope used in laparoscopy are known as laparoscopes and are used for complicated cases.


Can Pneumoperitoneum Lead To Pneumomediastinum?

The occurrence of both pneumomediastinum and pneumomediastinum in a single patient is rare with few reported cases. Pneumoperitoneum can lead to the development of pneumomediastinum. In COVID patients use of mechanical ventilation lead to the occurence of both conditions.


What Is the Advantage of Pneumoperitoneum?

During laparoscopic procedures creating pneumoperitoneum provides optimal working space and better visualization for instrumentation of the abdominal cavity. Pneumoperitoneum formation is an important step in laparoscopic surgery to prevent iatrogenic injury to major vessels and abdominal organs.
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Dr. Ghulam Fareed
Dr. Ghulam Fareed

Medical Gastroenterology


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