Case 4: Pneumoperitoneum in a 2-year-old Boy

Presentation

A 2-year-old, previously healthy Hispanic boy presents to an outside hospital emergency department with a 1-week history of abdominal pain and decreased appetite. On arrival his weight is 11.0 kg (5th percentile, z score: –1.6), he is febrile to 102.5°F (39.2°C), tachycardic to 206 beats/min, and tachypneic, breathing greater than 30 breaths/min. On physical examination he is pale with small abrasions to his face and bilateral upper extremities, lethargic, withdrawn, and malnourished appearing, with a firm and distended abdomen, diffuse tenderness to palpation, and hypoactive bowel sounds. Initial laboratory studies are obtained and are notable for a mild anemia (hemoglobin level, 10.9 g/dL [109 g/L]), a normal white blood cell count, hyponatremia (sodium level, 130 mEq/L), and normal lipase, aspartate aminotransferase/alanine aminotransferase, and lactic acid levels. Initial abdominal radiography (Fig 1) shows distended loops of bowel. Computed tomography (CT) of the abdomen and pelvis (Fig 2) reveals moderate, diffuse dilation of small and large bowel loops as well as moderate free intraperitoneal fluid and free intraperitoneal air. After receiving fluid resuscitation and broad spectrum antibiotics, the patient is transferred to a tertiary children’s hospital for surgical evaluation …