Idiopathic Air Under the Diaphragm, Laparotomy or Laparoscopy?

1.1.Back ground: Acute abdominal pain with air under the diaphragm is a sign of gastrointestinal perforation and an urgent laparotomy is usually recommended. 1.2.Case Presentation: 42-year-old female presented to Accident and Emergency (A&E) department with severe abdominal pain and chest X-ray showed (Figure 1) free gas under the diaphragm. She was known to have irritable bowel disease (constipation predominantly). She had an urgent laparotomy. Thorough examination of all internal organs was conducted but no abnormality was found. 1.3.Discussion: Acute abdominal pain and presence of pneumoperitoneum is a common acute surgical emergency. Commonest cause is visceral perforation. Other causes are knee-chest exercises, pelvic inflammatory disease, coitus, gynecological examination, vaginal douching and vaginal insufflation. In this particular case we didn’t find any causative factor. 1.4.Conclusion: The lesson from this case indicates that diagnostic laparoscopy should be the first line intervention especially for patients that have vague or inconclusive history and pre-operative cross sectional imaging. Pneumoperitoneum secondary to non-surgical causes is rare and laparotomy should be avoided in these patients.