Gastrointestinal
Gastrointest Radiol 1, 277-279 (1976)
Radiology .~) by Springer-Verlag 1976
Pneumoperitoneum and Appendicitis Jack Farman, E. George Kassner, Serge Dallemand, and H. David Stein Department of Radiology, Downstate Medical Center, Brooklyn, New York (JF, EGK, SD) and Department of Surgery, Albert Einstein College of Medicine, Bronx, New York (HDS), U.S.A.
Abstract. Pneumoperitoneum. was observed in five pa-
tients with acute perforative appendicitis (APA). In each case this radiographic observation led to an incorrect diagnosis. Free intraperitoneal gas is found in a small number of patients with APA and has no apparent effect on the course or prognosis of the disease. Key words: Appendicitis - Pneumoperitoneum.
Pneumoperitoneum has rarely been described in patients with acute perforative appendicitis (APA). We have seen five patients with APA who had obvious free intraperitoneal gas. In each instance this radiographic observation led to an incorrect preoperative diagnosis.
Clinical Material
The clinical, radiographic, and operative findings are summarized in Table 1. All five patients complained of localized abdominal pain; symptoms were present for 1 4 days before admission. None of the patients complained of shoulder pain. At the time of the initial radiographic examination four patients had physical signs of an acute process in the right lower quadrant and clinical evidence of peritonitis. In each instance APA was strongly considered, but the tentative diagnosis was changed to "perforated peptic ulcer" or "perforated viscus, site undetermined" when pneumoperitoneum was observed. One patient (case 5) had right upper quadrant tenderness for several days Address reprint requests to." Jack Farman,
M.B., Ch.B., M.Med., Dept. of Radiology,Downstate Medical Center, 450 Clarkson Ave. (Box 45) Brooklyn, NY 11203, U.S.A.
before admission; liver function tests revealed hepatocellular dysfunction. The tentative diagnosis of hepatititis was changed to " p r o b a b l e perforated peptic ulcer" after pneumoperitoneum was noted. The radiographic findings in two representative cases are shown in Figures 1 and 2. In each case operation revealed APA; four patients had generalized peritonitis. Only one patient (case 5) had an intraperitoneal abscess. Four patients survived. Case 2, an elderly woman with severe diabetes, died of sepsis on the 15th postoperative day.
Discussion
Plain radiographs of the abdomen are frequently abnormal in patients with APA; several radiographic signs strongly suggest this diagnosis [1, 2] (Table 2). Mobile collections of intraperitoneal gas are extremely rare in patients with APA. Frimann-Dahl [3] did not observe a discrete pneumoperitoneum ("sickle sign") in his review of the abdominal radiographs of more than 2000 patients with acute appendicitis, an unknown number of whom had APA. Recently published surgical texts do not mention the occurrence of pneumoperitoneum in patients with APA [4, 5]; the authors of one text have maintained that the radiographic observation of pneumoperitoneum virtually excluded this diagnosis [6]. Our review of the literature revealed that at least 55 examples of pneumoperitoneum associated with APA have been reported since 1923 [7, 8]. The absence of pneumoperitoneum in most patients with APA is not surprising: occlusion of the appendiceal lumen by inflammatory edema, pus, or coprolith presumably prevents leakage of intestinal gas [7]. We believe that in most instances pneumoperitoneum results from leakage of intestinal gas through
278
J. Farman et al. : Pneumoperitoneum and Appendicitis
Table 1 Case 1
Case 2
Case 3
Case 4
Case 5
Age
28 years
68 years
42 years
36 years
20 years
Sex
Male
Female
Male
Male
Male
Duration of symptoms
1 day
3 days
1 day
2 days
4 days
Localization of symptoms and physical signs
Right lower quadrant
Right lower quandrant
Right lower quadrant
Right lower quadrant
Right upper quadrant
Clinical signs of peritonitis
Yes
Yes
Yes
Yes
Yes
Clinical diagnosis
Perforated peptic ulcer
Perforated viscus
Perforated peptic ulcer
Perforated peptic ulcer
Hepatitis; perforated peptic ulcer
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Operative ,findings
Appendix Exudate
1500 ml
1000 ml
Present
Present
Not recorded
Culture
E. coli
E. coli
No culture
E. coli
No culture
Abscess
No
No
No
No
Subhepatic and paracolic
Position of appendix
Normal
Normal
Normal
Normal
Paracolic
Outcome
Uneventful recovery
Died 15 days after surgery
Uneventful recovery
Uneventful recovery
Uneventful recovery
appendices that are incompletely obstructed. Frimann-Dahl [3] has suggested that pneumoperitoneum might follow leakage of gas from a localized periappendiceal abscess; such abscesses were present in one of our cases and in several published cases. However pneumoperitoneum due to this mechanism must be
exceedingly rare, since periappendiceal abscesses are well-contained by the surrounding inflammatory reaction. Bacterial gas production within abdominal abscesses rarely has led to large gas collections in the lesser sac [2] and hepatorenal space (Rutherford Morison's pouch) [9] in patients with APA.
Fig. l. Case 1. Radiograph of chest showing free air under both hemidiaphragms
Fig. 2. Cas'e 2. Detail of left upper quadrant. There is free air under the left hemidiaphragm
J. Farman et al. : Pneumoperitoneum and Appendicitis Table 2. Plain radiographic findings in acute perforative appendicitis
Sig,s c~/"appendiceal and peri-appendieeal disease Coprolith ~ Gas-fluid level in cecum: cecal distension" Increased soft tissue density in right lower quadrant ~ Sentinel loop ileus (distended ileal loop) ~' Cecal edema ~ Mass effects on cecum and distal ileum Lumbar scoliosis Obliteration of properitoneal fat stripe Obliteration of distal psoas margin Gaseous distension and fixation of appendix ~ Small bowel obstruction (secondary to fibrinous adhesions) Gas bubbles in right lower quadrant ~
Signs o[ peritonitis Generalized ileus" Free fluid" Gas bubbles and gas-fluid collections remote from appendix ~ Modified from McCort [1] and Joffe [2] "
Most reliable signs
Perforation of a nongangrenous appendix has been known to occur: Rucker et al. [8] reported a massive pneumoperitoneum that apparently was due to a blowout of the appendix in an elderly w o m a n with obstructing carcinoma of the sigmoid colon. The presence of free intraperitoneal gas does not appear to alter the course or prognosis of patients with APA. The distribution and amount of intraperi-
279
toneal gas is similar to that observed in patients with perforated peptic ulcers. Thus radiographic and clinical signs which ordinarily suggest complicated appendicitis may be discounted. In one sense pneumoperitoneum may be considered a favorable sign, since this dramatic radiographic finding will generally lead to immediate laparotomy in patients in w h o m a "surgical a b d o m e n " had not previously been recognized. This happened in one of our patients (case 5), a young man who was believed to have hepatitis before pneumoperitoneum was observed.
References I. McCort J J: Extra-alimentary gas in perforated appendicitis. Amer J Roentgenol 84: 1087-1092, 1960 2. Joffe N : Radiology of acute appendicitis and its complications. Crit Rev in Clin Radiol & Nuel Med 7.'97-160. 1975 3. Frimann-Dahl J : Roentgen Examination in Acute Abdomhlal Diseases, pp. 373 374. Springfield, Ill.: Charles C Thomas 1967 4. Rhoads JE. Allen JG, Harkins HN, Moyer CH: Surge~3", Principles and Practice, p. 1047. Philadelphia: JB Lippincott Co 1970 5. Schwartz SI (editor): Principles o f Surgery, pp. 1167 1173. New York: McGraw-Hill Blakiston Division 1974 6. Moseley HF: Textbook o f Surgery, 3rd Edition, p. 919. St Louis: CV Mosby Co 1959 7. Chavez MC, Morgan BD: Acute appendicitis with pneumoperitoneum. Am Surgeon 32:604~08, 1966 8. Rucker CR, Miller RE, May HR: Pneumoperitoneum secondary to perforated appendicitis. Am Surgeon 33." 188 190, 1967 9. Movsas I : Gas in the hepato-renal space. An unusual radiologic sign of perforated appendicitis. S Aft" J Radiol 3.'35 37, 1965
Received: June 28, 1976," accepted: August 18, 1976
Gastrointest Radiol 1, 277-279 (1976)
Radiology .~) by Springer-Verlag 1976
Pneumoperitoneum and Appendicitis Jack Farman, E. George Kassner, Serge Dallemand, and H. David Stein Department of Radiology, Downstate Medical Center, Brooklyn, New York (JF, EGK, SD) and Department of Surgery, Albert Einstein College of Medicine, Bronx, New York (HDS), U.S.A.
Abstract. Pneumoperitoneum. was observed in five pa-
tients with acute perforative appendicitis (APA). In each case this radiographic observation led to an incorrect diagnosis. Free intraperitoneal gas is found in a small number of patients with APA and has no apparent effect on the course or prognosis of the disease. Key words: Appendicitis - Pneumoperitoneum.
Pneumoperitoneum has rarely been described in patients with acute perforative appendicitis (APA). We have seen five patients with APA who had obvious free intraperitoneal gas. In each instance this radiographic observation led to an incorrect preoperative diagnosis.
Clinical Material
The clinical, radiographic, and operative findings are summarized in Table 1. All five patients complained of localized abdominal pain; symptoms were present for 1 4 days before admission. None of the patients complained of shoulder pain. At the time of the initial radiographic examination four patients had physical signs of an acute process in the right lower quadrant and clinical evidence of peritonitis. In each instance APA was strongly considered, but the tentative diagnosis was changed to "perforated peptic ulcer" or "perforated viscus, site undetermined" when pneumoperitoneum was observed. One patient (case 5) had right upper quadrant tenderness for several days Address reprint requests to." Jack Farman,
M.B., Ch.B., M.Med., Dept. of Radiology,Downstate Medical Center, 450 Clarkson Ave. (Box 45) Brooklyn, NY 11203, U.S.A.
before admission; liver function tests revealed hepatocellular dysfunction. The tentative diagnosis of hepatititis was changed to " p r o b a b l e perforated peptic ulcer" after pneumoperitoneum was noted. The radiographic findings in two representative cases are shown in Figures 1 and 2. In each case operation revealed APA; four patients had generalized peritonitis. Only one patient (case 5) had an intraperitoneal abscess. Four patients survived. Case 2, an elderly woman with severe diabetes, died of sepsis on the 15th postoperative day.
Discussion
Plain radiographs of the abdomen are frequently abnormal in patients with APA; several radiographic signs strongly suggest this diagnosis [1, 2] (Table 2). Mobile collections of intraperitoneal gas are extremely rare in patients with APA. Frimann-Dahl [3] did not observe a discrete pneumoperitoneum ("sickle sign") in his review of the abdominal radiographs of more than 2000 patients with acute appendicitis, an unknown number of whom had APA. Recently published surgical texts do not mention the occurrence of pneumoperitoneum in patients with APA [4, 5]; the authors of one text have maintained that the radiographic observation of pneumoperitoneum virtually excluded this diagnosis [6]. Our review of the literature revealed that at least 55 examples of pneumoperitoneum associated with APA have been reported since 1923 [7, 8]. The absence of pneumoperitoneum in most patients with APA is not surprising: occlusion of the appendiceal lumen by inflammatory edema, pus, or coprolith presumably prevents leakage of intestinal gas [7]. We believe that in most instances pneumoperitoneum results from leakage of intestinal gas through
278
J. Farman et al. : Pneumoperitoneum and Appendicitis
Table 1 Case 1
Case 2
Case 3
Case 4
Case 5
Age
28 years
68 years
42 years
36 years
20 years
Sex
Male
Female
Male
Male
Male
Duration of symptoms
1 day
3 days
1 day
2 days
4 days
Localization of symptoms and physical signs
Right lower quadrant
Right lower quandrant
Right lower quadrant
Right lower quadrant
Right upper quadrant
Clinical signs of peritonitis
Yes
Yes
Yes
Yes
Yes
Clinical diagnosis
Perforated peptic ulcer
Perforated viscus
Perforated peptic ulcer
Perforated peptic ulcer
Hepatitis; perforated peptic ulcer
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Perforated, gangrenous
Operative ,findings
Appendix Exudate
1500 ml
1000 ml
Present
Present
Not recorded
Culture
E. coli
E. coli
No culture
E. coli
No culture
Abscess
No
No
No
No
Subhepatic and paracolic
Position of appendix
Normal
Normal
Normal
Normal
Paracolic
Outcome
Uneventful recovery
Died 15 days after surgery
Uneventful recovery
Uneventful recovery
Uneventful recovery
appendices that are incompletely obstructed. Frimann-Dahl [3] has suggested that pneumoperitoneum might follow leakage of gas from a localized periappendiceal abscess; such abscesses were present in one of our cases and in several published cases. However pneumoperitoneum due to this mechanism must be
exceedingly rare, since periappendiceal abscesses are well-contained by the surrounding inflammatory reaction. Bacterial gas production within abdominal abscesses rarely has led to large gas collections in the lesser sac [2] and hepatorenal space (Rutherford Morison's pouch) [9] in patients with APA.
Fig. l. Case 1. Radiograph of chest showing free air under both hemidiaphragms
Fig. 2. Cas'e 2. Detail of left upper quadrant. There is free air under the left hemidiaphragm
J. Farman et al. : Pneumoperitoneum and Appendicitis Table 2. Plain radiographic findings in acute perforative appendicitis
Sig,s c~/"appendiceal and peri-appendieeal disease Coprolith ~ Gas-fluid level in cecum: cecal distension" Increased soft tissue density in right lower quadrant ~ Sentinel loop ileus (distended ileal loop) ~' Cecal edema ~ Mass effects on cecum and distal ileum Lumbar scoliosis Obliteration of properitoneal fat stripe Obliteration of distal psoas margin Gaseous distension and fixation of appendix ~ Small bowel obstruction (secondary to fibrinous adhesions) Gas bubbles in right lower quadrant ~
Signs o[ peritonitis Generalized ileus" Free fluid" Gas bubbles and gas-fluid collections remote from appendix ~ Modified from McCort [1] and Joffe [2] "
Most reliable signs
Perforation of a nongangrenous appendix has been known to occur: Rucker et al. [8] reported a massive pneumoperitoneum that apparently was due to a blowout of the appendix in an elderly w o m a n with obstructing carcinoma of the sigmoid colon. The presence of free intraperitoneal gas does not appear to alter the course or prognosis of patients with APA. The distribution and amount of intraperi-
279
toneal gas is similar to that observed in patients with perforated peptic ulcers. Thus radiographic and clinical signs which ordinarily suggest complicated appendicitis may be discounted. In one sense pneumoperitoneum may be considered a favorable sign, since this dramatic radiographic finding will generally lead to immediate laparotomy in patients in w h o m a "surgical a b d o m e n " had not previously been recognized. This happened in one of our patients (case 5), a young man who was believed to have hepatitis before pneumoperitoneum was observed.
References I. McCort J J: Extra-alimentary gas in perforated appendicitis. Amer J Roentgenol 84: 1087-1092, 1960 2. Joffe N : Radiology of acute appendicitis and its complications. Crit Rev in Clin Radiol & Nuel Med 7.'97-160. 1975 3. Frimann-Dahl J : Roentgen Examination in Acute Abdomhlal Diseases, pp. 373 374. Springfield, Ill.: Charles C Thomas 1967 4. Rhoads JE. Allen JG, Harkins HN, Moyer CH: Surge~3", Principles and Practice, p. 1047. Philadelphia: JB Lippincott Co 1970 5. Schwartz SI (editor): Principles o f Surgery, pp. 1167 1173. New York: McGraw-Hill Blakiston Division 1974 6. Moseley HF: Textbook o f Surgery, 3rd Edition, p. 919. St Louis: CV Mosby Co 1959 7. Chavez MC, Morgan BD: Acute appendicitis with pneumoperitoneum. Am Surgeon 32:604~08, 1966 8. Rucker CR, Miller RE, May HR: Pneumoperitoneum secondary to perforated appendicitis. Am Surgeon 33." 188 190, 1967 9. Movsas I : Gas in the hepato-renal space. An unusual radiologic sign of perforated appendicitis. S Aft" J Radiol 3.'35 37, 1965
Received: June 28, 1976," accepted: August 18, 1976
