The n e w e ng l a n d j o u r na l of m e dic i n e

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Pneumoperitoneum

A B

Jonathan Ailon, M.D.
University of Toronto
Toronto, ON, Canada
jonathan.ailon@utoronto.ca
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 guard-
ing 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 decom-
press the abdomen and provide symptomatic relief. The patient died shortly there-
after.
Copyright © 2012 Massachusetts Medical Society.

e26 n engl j med 366;17 nejm.org april 26, 2012

The New England Journal of Medicine

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