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      Idiopathic pneumoperitoneum without gastrointestinal perforation in a low-birth weight infant: A rare type of air leak syndrome

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          Abstract

          Neonatal free air on X-ray images is generally due to intestinal perforation, and requires surgical intervention. However, some cases without intestinal perforation show free air on X-ray images. Pneumoperitoneum without perforation is caused by an air leak syndrome. We present here the case of a low-birth-weight infant with free air on X-ray images, who had no evidence of intestinal perforation intraoperatively.

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          Does pneumoperitoneum always require laparotomy? Report of six cases and review of the literature.

          The presence of intraperitoneal free air signals perforation of a hollow viscus in over 90% of the patients. Rarely, however, the presence of pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. This condition, which poses a dilemma to the surgeon faced with this problem, is termed "nonsurgical", "spontaneous" or "idiopathic" pneumoperitoneum. Six cases of nonsurgical pneumoperitoneum admitted over a 2-year period to our institution are reported, and the etiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas are reviewed. Two of the six children with nonsurgical pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in one of these patients. In the other children, malrotation was found. Four patients, on ventilatory support, were managed conservatively after performing a diagnostic peritoneal lavage and/or contrast studies those were negative. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum.
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            Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention.

            Air leak syndrome includes pulmonary interstitial emphysema, pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, subcutaneous emphysema, and systemic air embolism. The most common cause of air leak syndrome in neonates is inadequate mechanical ventilation of the fragile and immature lungs. The incidence of air leaks in newborns is inversely related to the birth weight of the infants, especially in very-low-birth-weight and meconium-aspirated infants. When the air leak is asymptomatic and the infant is not mechanically ventilated, there is usually no specific treatment. Emergent needle aspiration and/or tube drainage are necessary in managing tension pneumothorax or pneumopericardium with cardiac tamponade. To prevent air leak syndrome, gentle ventilation with low pressure, low tidal volume, low inspiratory time, high rate, and judicious use of positive end expiratory pressure are the keys to caring for mechanically ventilated infants. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) can provide adequate gas exchange using extremely low tidal volume and supraphysiologic rate in neonates with acute pulmonary dysfunction, and they are considered to have the potential to reduce the risks of air leak syndrome in neonates. However, there is still no conclusive evidence that HFOV or HFJV can help to reduce new air leaks in published neonatal clinical trials. In conclusion, neonatal air leaks may present as a thoracic emergency requiring emergent intervention. To prevent air leak syndrome, gentle ventilations are key to caring for ventilated infants. There is insufficient evidence showing the role of HFOV and HFJV in the prevention or reduction of new air leaks in newborn infants, so further investigation will be necessary for future applications.
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              Neonatal pneumoperitoneum: a critical appraisal of its causes and subsequent management from a developing country.

              The diagnosis and management of neonatal pneumoperitoneum revolves around necrotizing enterocolitis (NEC) in most of the published literature. Although NEC remains the major cause of pneumoperitoneum in a neonate, there are several other causes leading to free air in the peritoneal cavity. A number of case reports have appeared describing pneumoperitoneum in a newborn due to rupture of one particular organ, but there have been only few collective reviews on the subject. The present study shares the experience with neonates admitted with a diagnosis of pneumoperitoneum in a pediatric surgical center of a developing country. The various causes of pneumoperitoneum in a newborn, their management and subsequent outcome are described. The study was conducted in the Department of Pediatric Surgery, CSMMU (upgraded King Georges Medical College), Lucknow, India. All the neonates admitted with a diagnosis of pneumoperitoneum during the period of last 3 years (2005-2008) were retrospectively analyzed. Other neonatal admissions were also retrieved for the same period. Free air was confirmed by erect abdominal X-ray or lateral decubitus films in certain cases. The data sheets were analyzed regarding age of presentation, cause of bowel perforation, management offered and subsequent outcome achieved. All patients of NEC without evidence of perforation were not included in the study (n = 21). Out of total 537 neonatal admissions, 89 (16.5%) neonates were admitted with a diagnosis of pneumoperitoneum. There were 79 (88.7%) males and only 10 (11.6%) female neonates admitted during the study period. All of them had evidence of pneumoperitoneum at the time of admission. The age at presentation ranged from 4 to 32 days. NEC remained the single major cause of pneumoperitoneum in the newborn; however, in 44 (49.4%) patients the cause was not related to NEC. Perforated pouch colon, isolated colonic perforations, caecal perforations, gastric and duodenal perforations were the main causes of pneumoperitoneum not related to NEC. There were seven patients in whom no cause of pneumoperitoneum could be ascertained. The treatment was individualized according to the presentation. Most of the NEC-related perforations were managed by peritoneal drains. Laparotomy was done in rest of the patients. Three patients were managed conservatively. Overall, 19 (21.6%) patients expired. Most of those expired were of low birth weight with NEC and congenital pouch colon with perforation. Neonatal pneumoperitoneum remains a surgical emergency and outcome can be lethal if the problem is not addressed early. NEC remains the major cause; however, there are several other important causes of isolated gastrointestinal perforations leading to neonatal pneumoperitoneum. The management should be individualized in these patients and the outcome largely depends on the early recognition of the condition.
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                Author and article information

                Contributors
                Journal
                Radiol Case Rep
                Radiol Case Rep
                Radiology Case Reports
                Elsevier
                1930-0433
                07 May 2020
                July 2020
                07 May 2020
                : 15
                : 7
                : 926-928
                Affiliations
                [0001]Department of Pediatric Surgery, Shizuoka Children's Hospital, 860 Urushiyama, Aoi-ku, Shizuoka 420-8660, Shizuoka, Japan
                Author notes
                [* ] Corresponding author. hdnakaji@ 123456gmail.com
                Article
                S1930-0433(20)30141-2
                10.1016/j.radcr.2020.04.036
                7215104
                99dbe50f-e027-42f7-966f-a1b3a7c92dca
                © 2020 The Authors. Published by Elsevier Inc. on behalf of University of Washington.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 17 March 2020
                : 15 April 2020
                : 15 April 2020
                Categories
                Pediatric

                pneumoperitoneum,air leak syndrome,gastrointestinal perforation,surfactant insufflation,hfov, high-frequency oscillatory ventilation,nec, necrotizing enterocolitis,no, nitric oxide,rds, respiratory distress syndrome

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