C46-02 Breaking Boundaries: Pneumoperitoneum as an Unusual Sequela of COPD Exacerbation

Abstract Introduction Pneumoperitoneum is a common pathology and is often associated with visceral perforation; spontaneous pneumoperitoneum can occur due to non-surgical etiologies such as barotrauma in patients with pulmonary disease. COPD, and emphysema in particular, is prone to alveolar injury due to fragile alveolar walls. During a COPD exacerbation, increased intrathoracic pressures from severe bronchospasm, dynamic hyperinflation and coughing can result in alveolar rupture causing air dissection and migration into the peritoneal space. We present a case of COPD exacerbation leading to pneumoperitoneum. Case Report A.V. is a 69-year-old male with oxygen dependent COPD who presented to the emergency department with one week of productive cough and dyspnea. Upon presentation he was found to be septic, with leukocytosis, tachycardia and hypotension. Initial blood gas showed hypercapnic respiratory failure requiring BiPAP, systemic steroids, aggressive bronchodilators and empiric antibiotics. Chest radiographs at the time were significant for hyperinflated lungs, but no acute cardiopulmonary pathology. Viral studies on presentation were negative, though initial blood cultures were significant for ESBL Klebsiella. He was admitted to the ICU for ongoing management. Mr. A.V. required intermittent BiPAP for days and continued to have episodic labored breathing and violent coughing. On hospital day 5, he was found to have abdominal distension, increased girth. He underwent a CT of the abdomen and pelvis and was found to have large volume pneumoperitoneum without evidence of viscous injury or perforation. Surgery was consulted and performed an exploratory laparotomy, the results of which showed no viscous injury or pathology. Following surgery, A.V. was difficult to oxygenate and ventilate prompting him to remain intubated post procedure. Given his decompensation in pulmonary status, persistent septic shock state and post-operative status the patient’s family ultimately decided that further life support was not in line with the patient’s personal values and transitioned his care to comfort measures only. Discussion This case underscores the importance of considering pulmonary sources of free intraperitoneal air in patients with COPD presenting with abdominal radiographic findings. The pathophysiology involves alveolar rupture from elevated intra-alveolar pressure escaping into the interstitial space, tracking inferiorly through the diaphragmatic hiatuses. Clinically, distinguishing barotraumatic pneumoperitoneum from visceral perforation is essential to ensure appropriate treatment. Management is typically conservative, with focus on treating the COPD exacerbation and optimizing ventilation while reducing barotrauma. Image: This abstract is funded by: None