Postgrad Med J: first published as 10.1136/pgmj.62.723.31 on 1 January 1986. Downloaded from Postgraduate Medical Journal (1986) 62, 31-32
Diagnostic Images
Pneumoperitoneum
Presented by L. Kreel Newham General Hospital, London E13, UK.
The patient A male age 66 years was admitted with a 6 month history of abdominal distension, and attacks of central abdominal pain and vomiting. The provisional diagnoses were cholelithiasis or chronic pancreatitis. Chest and abdominal radiographs were ordered (Figures 1 and 2), and oesophagogastroduodenoscopy performed which was normal. Barium enema showed diverticula of the sigmoid colon; small bowel enema was then carried out. by copyright. http://pmj.bmj.com/ on September 27, 2021 by guest. Protected
Figure 1 Chest radiograph showing pneumoperitoneum Figure 2 Supine abdominal film. The wall ofthe colon is with more gas under the left hemidiaphragm than under clearly visible because of the gas both within the lumen the right. and in the peritoneal cavity. In addition there are small 'balloons' (arrows) containing gas with clearly demar- cated walls due to large small bowel diverticula. Colonic diverticula ofthe sigmoid are also shown, from a previous barium enema. D The Fellowship of Postgraduate Medicine, 1986 32 DIAGNOSTIC=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..:e..IMAGES Postgrad Med J: first published as 10.1136/pgmj.62.723.31 on 1 January 1986. Downloaded from
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Figure 3z 1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... 'Small bowel enema (enteroclysis) demonstrat- Figure 4 Multiple diverticula of the small bowel shownby copyright. ing multiple duodenal diverticula. on small bowel enema. Diverticula of the sigmoid colon (arrows) from a previous barium enema are also visible.
Comment Diverticula are found throughout the whole alimentary tract from the upper oesophagus to the distal colon with a marked variation in size and aetiology occurring most commonly in the siginoid colon and duodenum. Most diverticula are asymptomatic butcomplications include food retention particularly in Zenker's diverticulum in the hypopharynx. Haemorrhage is associated with a Meckel's diverticulum ofthe terminal ileum and pericolic abscesshttp://pmj.bmj.com/ with sigmoid diverticula where there is usually marked circular muscle spasm. Colonic diverticula can also perforate. Duodenal diverticula are common and almost always asymptomatic while those in the small bowel may produce malabsorption. Two papers reporting rare complications of the diverticula in the latter two sites have appeared in recent issues of this Journal (Stebbings & Thomson, 1985; Clarke & Kettlewell, 1985). Although this patient had sigmoid diverticula, perforation of a diverticulum in this region is usually into retroperitoneal tissues and not free into the peritoneal cavity. While not proven, perforation of a small bowel diverticulum was considered to be the most likely source ofthe pneumoperitoneum. The patient's symptoms were on September 27, 2021 by guest. Protected attributed to the pneumoperitoneum and disappeared as the pneumoperitoneum resolved.
References
STEBBINGS, W.S.L. & THOMSON, J.P.S. (1985). Perforated CLARKE, P.J. & KETTLEWELL, M.G.W. (1985). Small bowel duodenal diverticulum: a report oftwo cases. Postgraduate obstruction due to an enterolith originating in a jejunal Medical Journal, 61, 839. diverticulum. Postgraduate Medical Journal, 61, 1019.