Diagnostic Artificial Pneumoperitoneum

The artificial introduction of air into the peritoneal cavity as an important part of the medical management of tuberculosis is widely known. The use of this procedure as a vital diagnostic tool, however, is less familiar. We are convinced that it is unexcelled for the diagnosis of upper intra-abdominal masses outside of the stomach and intestines, especially if it is combined with a contrast study of the gastrointestinal tract. The procedure is simple and innocuous and devoid of any unpleasant sequelae, since the amount of air introduced is much less than is ordinarily employed in therapeutic artificial pneumoperitoneum. It is thus handy and convenient, as it can easily be performed on an outpatient basis.

Our technic consists simply in the introduction of a 22-gauge needle by a right or left para-umbilical route, the same needle being used for local anesthesia and for penetrating the peritoneal cavity. If the patient is obese, a 22-gauge spinal needle is used following local anesthesia. To determine the position of the needle, an aspiration test is done. If no air is aspirated, the needle is either within the peritoneal cavity or in the anterior abdominal wall. If air is aspirated, the needle has penetrated the intestine. Usually, during the puncture one gets a sensation of giving way as the needle is pushed deeper. This indicates that the tip of the needle has penetrated the peritoneum into the abdominal cavity. As a further test, 30 c.c. of air is introduced with a 50-c.c. syringe. If the tip of the needle lies within the peritoneal cavity, no resistance is encountered as the plunger of the syringe is pushed in. After the needle is in place, from 300 to 500 c.c. of air, depending on the size of the patient, is introduced with the aid of a 50-c.c. syringe and a three-way stopcock. The needle is withdrawn and the patient is placed in a prone position for five minutes, with the table tilted upward about 30 °. Postero-anterior, right and left anterior oblique, and upright films of the abdomen are then taken. If the lesion in question is close to the diaphragm, upright chest films are obtained in various projections. Whenever the mass protrudes anteriorly, a translateral film of the abdomen with the patient supine is taken, with a fine grid.

Illustrative Cases

Case I: A 48-year-old Chinese salesman was admitted to the hospital complaining of jaundice and general body weakness. His present illness dated back six months, when he first experienced vague upper abdominal discomfort and impairment of appetite associated with a slowly progressive weight loss. At the time of admission he had lost approximately 20 pounds. Four months after the onset, he noticed that he was becoming pale and slightly yellow, the yellowish tinge being especially prominent in his eyes. At the same time, he began to have some ill-defined intermittent pain in the upper abdomen, sometimes localized on the right and occasionally radiating to the back.