Asian Journal of Case Reports in Surgery

Introduction: Pneumoperitoneum is considered a surgical emergency, as it is highly associated with abdominal viscus perforation. Pulmonary origin of pneumoperitoneum secondary to invasive mechanical ventilation in severe COVID-19 pneumonia has been rarely reported in the existing literature.

Presentation of Case: A 62-year-old female was diagnosed with stage 5 COVID-19 pneumonia and was intubated due to respiratory distress. She subsequently developed pneumomediastinum, pneumothorax, subcutaneous emphysema and pneumoperitoneum a few days post-intubation. However, there was no radiological evidence of abdominal viscus perforation from a computed tomography (CT) scan. Coupled with clinical findings and blood investigation, the patient was managed non-surgically with bilateral chest tubes and close monitoring of the intra-abdominal pressure. The pneumoperitoneum resolved a few days later. However, the patient continued to deteriorate throughout her stay at the ICU, due to concurrent nosocomial sepsis with kidney failure. Ultimately, the patient passed away on day 14 of her hospital stay.

Discussion: The management of pulmonary origin of pneumoperitoneum is mainly conservative with close observation of intra-abdominal pressure. Unnecessary non-therapeutic laparotomy of such a condition will potentially increase the mortality and morbidity of critically-ill COVID-19 patients.

Conclusion: Pneumoperitoneum resulting from severe COVID-19 pneumonia should be managed non-operatively, provided there is clear evidence of the absence of viscus perforation. A radiological examination, coupled with clinical findings and blood investigation, is crucial in establishing an accurate diagnosis.