Pneumoper itoneum By : Rafi Mahandaru / 2013
Jun 02, 2015
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..,