Spontaneous pneumoperitoneum in a case of multiple intestinal diverticulosis in an elderly female admitted for intertrochanteric fracture

Abstract

Spontaneous pneumoperitoneum refers to the presence of free intraperitoneal air without perforation of a hollow viscus and accounts for less than 10% of all cases of pneumoperitoneum. It is a rare clinical entity and often poses a diagnostic challenge, especially in elderly patients presenting with signs suggestive of perforation peritonitis. It even more rare to encounter this case on regular rounds in the orthopaedic ward. We report the case of an 85-year-old female admitted for left intertrochanteric femur fracture following a fall, who developed abdominal distension and generalized abdominal pain on the fourth day of trauma. Clinical examination revealed abdominal distension, tenderness and guarding, raising suspicion of perforation. Contrast-enhanced computed tomography demonstrated pneumoperitoneum with multiple diverticula involving the ileum, ascending colon and transverse colon. Emergency exploratory laparotomy was performed due to clinical signs of peritonitis and pneumoperitoneum on CT. Intraoperatively, multiple diverticula were identified in the duodenum, proximal ileum, ascending colon and transverse colon, with inflammatory changes in the omentum and multiple adhesions, but no gastrointestinal perforation was found. This case highlights the importance of considering spontaneous pneumoperitoneum in elderly patients with diverticulosis and emphasizes that surgical exploration may still be necessary when clinical findings strongly suggest perforation despite the absence of an actual bowel perforation.