Benign post-traumatic pseudopneumoperitoneum

Last revised by Mostafa El-Feky on 2 Aug 2021

Benign post-traumatic pseudopneumoperitoneum is the presence of ectopic gas typically between the 5th-10th intercostal spaces after high-energy trauma in the absence of other causes of pseudopneumoperitoneum such as pneumomediastinum 9

Occurs with an incidence of 5% post-trauma (after excluding known causes for pseudopneumoperitoneum). The true incidence is unknown and difficult to determine but probably higher than this.

Typically younger patients sustaining high-velocity trauma.

Pseudopneumoperitoneum is a well recognized post-traumatic phenomenon in patients with pneumomediastinum and pulmonary interstitial emphysema 1-4 where the gas is able to track down pressure gradients along tissue planes into the retroperitoneum (via the diaphragmatic apertures) and extraperitoneal space (via the foramen of Morgagni) 1-7 by a process called Macklin effect 8.

A further relatively common, but under recognized cause for post-traumatic pseudopneumoperitoneum in trauma has recently been described 9. The finding is clinically benign, mutually exclusive from other causes of pseudopneumoperitoneum 9

The hypothesized mechanism for ectopic gas production mimicking pseudopneumoperitoneum is by vacuum phenomenon.  Rapid changes in local tissue pressure, acute fractures or acute soft tissue disruption can cause dissolution of nitrogen gas from the adjacent soft tissues resulting in small pockets of gas visible on CT 14. The association of benign post-traumatic pseudopneumoperitoneum with high-velocity trauma supports this theory, by the fact that rapid changes in local tissue pressure from an external impact or local tissue disruption (diaphragmatic ligament attachment tears or costochondral microfractures) could create the required microenvironment for vacuum phenomenon.

Between the 5th-10th intercostal spaces adjacent to the costochondral junctions and anterior diaphragmatic attachments.

There is a statistically significant association with high-velocity trauma (with an incidence of 12.5% of all high-velocity trauma) 9.

Small pockets of gas located anteriorly between the 5th and 10th intercostal spaces, near the costochondral junctions. The gas often strongly resembles pneumoperitoneum. On closer inspection, the gas may be appreciated external to the peritoneal surface. In many instances, however, the exact location of the gas is unable to be accurately resolved with CT.   

The finding is clinically benign but important to discriminate from true pneumoperitoneum in order to prevent clinical uncertainty. Ectopic gas occurring in the typical distribution for benign post-traumatic pseudopneumoperitoneum in a patient without ancillary imaging features for bowel injury should prompt the reader to consider this as a cause for the finding. 

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Cases and figures

  • Case 1
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