see pneumoperitoneum

Pneumoperitoneu

mBy : Rafi Mahandaru / 2013

By : Rafi Mahandaru / 212

Pneumoperitoneum

Background Pneumoperitoneum is a common medical

problem in a recent year As the surgical treatment increase Usually unnoticed by practitioner due to

insidious symptom Severe case can lead to unwanted

complication Diagnosis can be done by GP Once diagnostic proof, severe case

confirm immediate treatment should achieved by the patient

Anatomical Review

Physiological Aspects

Intra Abdominal Pressure (5-7mmHg) (BMI, Position, Diseases)

Abdominal Perfusion Pressure (0-7mmHg APP = MAP - IAP

Etiology Ruptur viskus berongga (yaitu perforasi ulkus

peptikum, necrotizing enterocolitis, megakolon toksik, penyakit usus inflamasi)

Faktor iatrogenik (yaitu pembedahan perut terakhir, trauma abdomen, perforasi endoskopi, dialisis peritoneal, paracentesis)

Infeksi rongga peritoneum dengan organisme membentuk gas dan atau pecahnya abses yang berdekatan

Etiology

Perforated viscus organ ( 41% )Residual Air (37 %)

Peptic ulcer (16%)Diverticulitis (16%)Trauma (14%)

Non surgicalRetained post operative air (25 – 60 %)Peritoneal dialysis and catheter placement (0,3 – 25 %)

Another Source

Pneumoperitonium

Dengan Peritonitis

Perforated viskus

Necrotizing enterocoliti

s

Infark usus

Cedera perut

Tanpa peritonitis

Thorax Abdomen

pelvis

DP ABDOMEN

THORAX

ABDOMEN

PELVIS

CLINICAL SIGN

Perforation :- Intense abdominal pain- Abdominal fullness- Shoulder pain

- Acute distress dsypnea- Abdominal tension- Tenderness- Tympanic and rigid- Rectal Prolapse ???- Crepitus- Hypovolemic Shock immediate decompression

Depen on the Causes and size :

Benign may be asymptomatic

Vague abdominal pain

Viscus organ rupture :Peritonitis sign

Onset Depend on organ

Immediate laparotomy

PATOGENESIS•CO2 absorbed•Hypercapnea•Pulmonary vasoconstriction•ANS tachycardia•Depressive effect on miocardium

• Cardiac index decrease 30%

during 30 minutes initiation of

pneumoperitoneum• Decrease cardiac

output (CO) hemodynamic disturbances

Decrease urine outputIncrease AldosteronDecrease Creatinin

clearance

Elevated liver enzymDecrease portal Venous flow

DIAGNOSISPurpose Entrapment of free air in the peritoneal cavity is

the key

Holistic history taking and Physical Examination the most important Already mentioned above !!!

Radiological Confirming Thorax X-Ray erect Best Right or Left Lateral Decubitus is allright ! USG, CT and MRI

X- Ray Semilunar Shadow

gambaran udara (radiolusen) berupa daerah berbentuk bulan sabit (Semilunar Shadow) diantara diafragma kanan dan hepar atau diafragma kiri dan lien

Decubitus Abdomen Sign

Terdapat udara bebas diantara dinding abdomen dengan hepar (panah putih). Ada cairan bebas di rongga peritoneum (panah hitam).

Anterior Subhepatic Space Free Air

Linear ShapeTriangular Shape

Geograpichal Sign

Density difference defining

Doges Cap Sign

Morison PouchHepato-RenalRecesses

Anterior View of Hepatic Surface

Foot Ball Sign >1000 ml air collected abdominal

decompression

Here Comes the MASSIVE ones

Gas-Relief Sign, Rigler Sign or Double Wall Sign

memvisualisasikan

dinding terluar

lingkaran usus

disebabkan udara

di luar lingkaran

usus dan udara

normal intralumen

Urachus Signudara tampak melapisi urachus. Urachus tampak seperti garis tipis linier di tengah bagian bawah abdomen yang berjalan dari kubah vesika urinaria ke arah kepala. Dasar urachus tampak sedikit lebih tebal daripada apeks.

Telltale Triangle Sign

menggambarkan daerah segitiga udara diantara 2 lingkaran usus dengan dinding abdomen

Try To Guess ???

Rigler’s Sign

Foot Ball sign

Foot ball signFalciform

ligament’s sign

CT - Scan Standard Radiological examination Not necessarily needed

Benefit : Detect, intraluminal free air Not depend on position and technique What X-Ray can’t shows and if it not specific

Disadvantage : High cost Can’t locate perforation Beside the intraluminal fluid is not specific for

pneumoperitoneum

Differential Chilaiditi’s syndrome (interposition

hepatodiapragmatica, subphrenic displacement of the colon, pseudopneumoperitoneum)

Basal Lung Atelectasis (colapsed alveoli – linear form, pneumonia, COPD, TBC )

Subphrenic abcess (acute pancreatitis, peritonitis)

Peritonitis

Management When ur patient has proven for

pneumoperitoneum -- Find the Underlying Causes

Unstable means Delay Stabilize A , B , C Management Abdominal

decompression Stable Confirm

Diagnostic confirm

immediate

< 20 % can be

managed by non-

surgical approach

In patients with small

amount of

intraperitoneal air

Without sign of

peritonitis

Patients should

receive

• intravenous fluid

•Absolute bowel rest

•Intravenous broad

spestrum antibiotic

•Get better on two

days > 50%

Symptomatic patient

with proof of

peritonitis

Laparotomy

(standard surgical

management)

Conclusion Pneumoperitoneum akumulasi udara pada rongga

peritonel Penyebab terbanyak adalah ruptur Hollow Viscus

Abdominal Organ karena berbagai sebab Diagnosis dapat dibuat dengan anamnesis dan

pemeriksaan fisik yang teliti Diagnosis radiologi (X-ray, CT-scan, USG, MRI)

sebagai konfirmasi sangat penting dalam mendiagnosis

Penanganan yang cermat dan tepat waktu meliputi stabilisasi hemodinamik dan penemuan penyakit terkait sangat penting untuk mengurangi mortalitas dan morbiditas pasien

Refferences ME ,Breen, Dorfman M, Chan SB. 2008. Pneumoperitoneum Without Peritonitis: A Case

Report.Am J Emerg Med, 26:841. e1-2 Churchill , James D Begg . 2006. Abdominal X-rays Made Easy 2nd Edition. Elsevier Khan, Ali Nawaz. 2011. Pneumoperitoneum Imaging : A Journal Diunduh dari http://emedicine.medscape.com, pada 8 Oktober 2012 Daly,  Barry D, J. Ashley Guthrie and Neville F. Cause of Pneumoperitoneum: A Case

Report. United Kingdom Mansjoer , Arif,dkk. 2000.Bedah Digestif. Kapita Selekta Kedokteran Jilid 2 Edisi Ketiga

(pp 240-252). Jakarta: Balai Penerbit FKUI. Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson,

Joseph Loscalzo, Eds. 2008. Harrison’s Principle of Internal Medicine 17 th Edition. USA : The McGraw-Hill Companies.

CH, Lee. 2010. Imaging Pneumoperitoneum : A Journal Diunduh dari

http://www.meddean.luc.edu/lumen/MedEd/Radio/curriculum/Surgery/pneumoperitoneum.htm pada 8 Oktober 2012

Weerakkody , Yuranga dan Jeremy Jones.Pneumoperitoneum. Diunduh dari http://radiopaedia.org/articles/pneumoperitoneum pada 8 Oktober 2012 Silberberg , Phillip. 2006. Pneumoperitoneum. Kentucky, USA. Derveaux ,K., F Penninckx. 2007. Crash Courses of Pneumoperitoneum. University

Leuven Belgia

Thanx..,