Pneumoperitoneum Caused by Ruptured Gas-Containing Pyogenic ...

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J Emerg Crit Care Med. Vol. 23, No. 1, 2012
Table 3 Poor prognostic factors of pyogenic liver abscess
APACHE II score at admission ≥15 Compromised immune status
Malignancy
Diabetes mellitus
Uremia
Senility
Hyperbilirubinemia 1 High level of blood creatinine 2
High level of blood urea nitrogen 3
Hyperglycemia
MDR isolates
Bacteremia
Polymicrobial infection 4 Anaerobic infection 4
Non-K. pneumoniae infection 4
Antibiotics alone
Diagnostic delay
Multiple abscesses
Bi-lobe involvement
Gas-forming liver abscess
Alveolar gas pattern and pneumoperitoneum as viewed on radiographs
Globular configuration, shaggy margin, alveolar internal structure, and total gas content on CT scans.
APACHE = Acute Physiology And Chronic Health Evaluation, MDR = multi-drug resistant, K. pneumoniae
= Klebsiella pneumoniae, 1 = blood total bilirubin > 20.52 μmol/L, 2 = blood creatinine > 115 μmol/L, 3 =
blood urea nitrogen>7.86 mmol/L, 4 = isolated pathogen growing in blood or abscess cultures
Klebsiella pneumonia and Escherichia coli (18) . The
impairment of local perfusion may also inhibit the
removal of gas from the infected tissue and cause
the GPLA (5) . However, if rupture of PLA occurs
and signs of acute peritonitis present, surgery
is the only treatment for this condition (5) . Poor
prognostic factors of PLA are listed at Table 3 (19,20) .
Multivariate analysis revealed that gas-forming
abscess, multi-drug resistant isolates, anaerobic
infection, blood urea nitrogen level >7.86 mmol/l,
and APACHE II score ≥15 were associated with
high mortality (20) .
I n s u m m a r y, i n s o m e o f t h e c a s e s o f
pneumoperitoneum, the physicians didn’t make
a proper diagnosis until surgical intervention.
Pneumoperitoneum with acute abdominal pain is
mostly secondary to hollow organ perforation, but
there are still some other causes which present the
similar clinical condition. Rupture of GPLA is a
rare one of them and can mimic intra-abdominal
visceral perforation. When physicians meet patients
who have pneumoperitoneum with acute abdominal
pain and the clinical clues of PLA exist. It must
be borne in mind that rupture of GPLA is one
of the differential diagnoses. Further abdominal
sonography, even abdominal CT scan is needed to
establish the proper diagnosis for immediate and
definite managements.
References
1. Mularski RA, Sippel JM, Osbrone ML.
Pneumoperitoneum: a review of nonsurgical
causes. Crit Care Med 2000;28:2638-44.
2. Mularski RA, Ciccolo ML, Rappaport WD.
Nonsurgical causes of pneumoperitoneum.
West J Med 1999;170:41-6.
3. Lee CH, Leu HS, Wu TS, Su LH, Liu JW. Risk
factors of spontaneous rupture of liver abscess
caused by Klebsiella pneumoniae. Diagn
Microbiol Infect Dis 2005;52:79-84.
4. Chou FF, Sheen-Chen SM, Lee TY. Rupture
of pyogenic liver abscess. Am J Gastroenterol
1995;90:767-70.
5. Ukikusa M, Inomoto T, Kitai T, et al.
Pneumoperitoneum following the spontaneous