Subdiaphragmatic free gas

Case contributed by Dr Jane McEniery

Presentation

Lower abdominal pain, nausea and vomiting. Previous bowel resection for complicated appendicitis.

Patient Data

Age: 13 years
Gender: Female
X-ray

Free gas below both domes of the diaphragm. The lungs and pleural spaces are clear. 

Case Discussion

The patient underwent emergency laparotomy. A perforation was present in the distal ileum, which was partially adherent to the bladder dome. The perforation was resected.

HISTOPATHOLOGY

MACROSCOPIC: Resected segment of small bowel, with a 12 x 10mm perforation. No stricture or tumor.

MICROSCOPIC: Sections of the segment of small intestine show significant acute peritonitis, as well as areas of fibrous thickening with fibrovascular proliferation. In some areas the muscle layer is attenuated or missing, commonly seen in cases of adhesive small bowel disease. The mucosa appears relatively normal in the intestinal segment, and there is no evidence of transmural inflammation, prominent lymphoid aggregates or neuromuscular proliferation. No granulomas or parasites can be seen. There is no dysplasia or malignancy.

COMMENT: The perforated segment of small intestine does not show evidence of Crohn's disease or other primary inflammatory process. The presence of dense fibrous adhesions as well as focal loss of muscularis propria adjacent to these is suggestive of adhesive small bowel disease, and this may have been a cause of acute obstruction. There is no evidence of Crohn's disease or any neoplastic or inflammatory disorder.

This patient previously required a right hemicolectomy for complicated appendicitis, which was the likely cause of the adhesions.

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