Pneumoperitoneum Caused by Ruptured Gas-Containing Pyogenic ...

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J Emerg Crit Care Med. Vol. 23, No. 1, 2012
Fig. 1
The upright chest X-ray showed small air bubbles (black
arrow) superimposing at upper liver area, which were
suggestive of a gas-containing pyogenic liver abscess (GPLA)
90 U/L, total bilirubin 0.8 mg/dL, alkaline
phosphatase 123 U/L. Then he was admitted
under the impression of newly-diagnostic diabetes
mellitus (DM), pneumonia and impairment of liver
function test, nature to be determinated.
Abdominal sonography was scheduled on next
day. However, sudden onset of abdominal pain
over right upper quadrant (RUQ) with vomiting
occurred on the second day. Physical examination
revealed diffuse tenderness, especially over RUQ,
with muscle rigidity and rebounding pain, but
the absence of Murphy’s sign. First look of the
second upright CXR (Fig. 2) showed bilateral
subphrenic free air and right side pleural effusion.
Second look of the first (Fig. 1) and the second
(Fig. 2) upright CXR revealed small air bubbles
superimposed at upper liver area was suggestive
of GPLA. Abdominal computed tomography (CT)
scan (Fig. 3) disclosed a big GPLA in right lobe of
liver, 11.6 x 10 x 6.8 cm in size, intra-abdominal
free air, ascites and right side pleural effusion. An
emergency surgical intervention was conducted
under the tentative diagnosis of secondary
peritonitis due to ruptured GPLA.
After surgical intervention, peritoneal lavage,
drainage, antibiotic treatment and strict control of
blood glucose, the infection was well controlled and
he was discharged smoothly on the postoperative
14th day. Cultures of blood and ascites yielded
Klebsiella pneumoniae.
Discussion
Pneumoperitoneum usually can be detected
by upright chest and left lateral decubitus of
abdomen radiographs, but CT scan is more sensitive
to detect than upright CXR (7) . In 5 to 15% of
cases, pneumoperitoneum does not reflect intra-