Idiopathic pneumoperitoneum: two cases with possible association to elevated intraluminal pressure

Pneumoperitoneum is an uncommon condition characterized by free gas in the abdominal cavity, usually resulting from gastrointestinal (GI) tract perforation and requiring emergency surgery. Idiopathic pneumoperitoneum is a rare condition with no identifiable cause and might be managed conservatively in stable patients without peritonitis signs. We report two cases of idiopathic pneumoperitoneum diagnosed by Computed tomography (CT) scan without obvious evidence of GI perforation. The etiology remains unclear, the more plausible explanation would be that increased intraluminal or intra-abdominal pressure induced by intestinal obstruction or constipation may contribute to occult micro perforation or mucosal disruption, which may not be detectable on contrast-enhanced CT imaging. The patients exhibited varied clinical presentations and responded well to conservative management, with complete clinical recovery. This report aims to emphasize the diagnostic challenges in differentiating idiopathic pneumoperitoneum from surgically urgent causes of pneumoperitoneum and to advocate for an appropriate approach to conservative management in stable patients, even when CT imaging demonstrates free intraperitoneal gas.