Hrev_master


A rare cause of pneumoperi-
toneum
Daniel Poor,1 Mayra Ramirez,2

Terrance McGovern,1 Ninad Shroff1

1Department of Emergency Medicine, St.
Joseph’s Regional Medical Center,
Paterson, NJ; 2School of Medicine, New
York Medical College, Valhalla, NY, USA

A 22-year-old female with no past med-
ical history presented to the emergency
department with a two-day history of diar-
rhea and left shoulder pain when lying
down which was alleviated by sitting
upwards.  She had a blood pressure of
103/62, pulse rate of 78 beats per minute
and a temperature of 36.6°C.  Abdominal
exam was unremarkable and the rest of the
physical exam was within normal limits. A
chest X-ray (Figure 1) was ordered due to
the patient’s complaint of shoulder pain
which demonstrated apparent pneumoperi-
toneum. She was taken emergently to the
operating room for operative management
of a suspected bowel perforation.    An
exploratory laparotomy was negative for an
intraperitoneal injury and attention subse-
quently turned to the free fluid in the poste-
rior cul-de-sac. OB/GYN was called to the
operating room and a 6 cm laceration in the
posterior cul-de-sac was identified which

fully penetrated the vaginal wall. The lacer-
ation was repaired and the patient was dis-
charged the following day. Upon further
questioning, the patient admitted to recently
having aggressive sexual intercourse with a
new partner and it was since these encoun-
ters that her symptoms began.

In addition to the typical causes of
pneumoperitoneum, there can be various
forms of vaginal trauma due to coitus or
intravaginal mechanical trauma including
douching and postpartum exercises that can
result in relatively asymptomatic pneu-
moperitoneum.1-3 Regardless of the etiolo-
gy, the finding of free air in the abdominal
cavity requires surgical consultation for
potential surgical management.  

References
1. Selvakumari N, Simons A, Ahmad G.

A rare cause of pneumoperitoneum.
JSCR 2011;11:8.

2. Johnson EK, Choi YU, Jarrard SW, et
al. Pneumoperitoneum after rough sex-
ual intercourse. Am Surg 2002;68:430-
3.

3. Jacobs VR, Mundhenke C, Maass N, et
al. Sexual activity as cause for non-sur-
gical pneumoperitoneum. JSLS
2000;4:297-300.

                                                       Emergency Care Journal 2017; volume 13:6606

Correspondence: Terrance McGovern,
Department of Emergency Medicine, 703
Main Street, Paterson, NJ 07503, USA.
Tel: (703)431-0165 - Fax: (973)754-2516.
Email: terrance.mcgovern@gmail.com

Key words: Pneumoperitoneum, Vaginal per-
foration, Acute care surgery.

Contributions: DP and NS took care of the
patient in the Emergency Department and
assisted in editing the final manuscript. MR
and TM drafted and edited the manuscript.

Conflict of interest: the authors declare no
potential conflict of interest.

Received for publication: 31 January 2017.
Revision received: 29 April 2017.
Accepted for publication: 4 May 2017.

This work is licensed under a Creative
Commons Attribution 4.0 License (by-nc 4.0).

©Copyright D. Poor et al., 2017
Licensee PAGEPress, Italy
Emergency Care Journal 2017; 13:6606
doi:10.4081/ecj.2017.6606

Figure 1. Upright anterior-posterior upright chest X-ray of a 22-year-old, sexually active,
female demonstrating suspected pneumoperitoneum.

                                                                       [Emergency Care Journal 2017; 13:6606]                                                      [page 33]

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