Not All Pneumoperitoneum Needs a Knife

ABSTRACT Pneumoperitoneum, the presence of free air in the peritoneal cavity, is most commonly associated with hollow viscus perforation, necessitating urgent surgical intervention. However, in rare cases, pneumoperitoneum can result from thoracic air leaks and may be managed conservatively unless it is causing diaphragmatic splinting. The aim of the study was to raise awareness about pneumoperitoneum secondary to pneumothorax, emphasizing nonoperative management to prevent unnecessary surgical interventions and associated morbidity. A 1-month-old female infant presented with respiratory distress requiring mechanical ventilation. Following intubation, the child deteriorated clinically, developing significant abdominal distension. Chest X-ray and abdominal X-ray revealed bilateral pneumothorax and pneumoperitoneum. Bilateral intercostal drains (ICDs) were placed, but due to worsening abdominal distension, an exploratory laparotomy was performed within a few hours. No evidence of hollow viscus perforation was found. Tense pneumoperitoneum confirmed with gush of air on opening the abdomen. The presence of air inside the left paracolic gutter extending to the diaphragm indicating it is from pneumothorax. The abdomen was closed with a drain, which was removed after 48 h. Feeds were initiated after 48 h. ICD was removed after 5 days and she was discharged after 7 days. Spontaneous pneumoperitoneum secondary to pneumothorax is an uncommon but important differential diagnosis. Recognizing key clinical clues, such as absence of gastrointestinal symptoms, history of respiratory distress, and extraperitoneal air on imaging, can facilitate conservative management, avoiding unnecessary surgical intervention.