Spontaneous pneumoperitoneum in an older adult with uncomplicated COVID-19: A case report

Pneumoperitoneum typically signifies gastrointestinal perforation and warrants urgent surgical intervention. However, spontaneous pneumoperitoneum (free intraperitoneal air without a clear cause) is an uncommon clinical entity. In the context of COVID-19, pneumoperitoneum is most frequently reported among patients receiving mechanical ventilation, typically due to barotrauma. Pneumoperitoneum in nonventilated, clinically stable patients is exceedingly rare.

We report a case of a 75-year-old man with well-controlled diabetes mellitus who presented with mild COVID-19 symptoms, managed as an outpatient. He later developed acute abdominal distension and pain. Clinical evaluation revealed mild diffuse tenderness without peritonitis. An erect abdominal X-ray demonstrated free subdiaphragmatic air consistent with pneumoperitoneum, but no signs of bowel obstruction, such as multiple air-fluid levels or significant bowel dilatation. Conservative management was initiated in the absence of peritoneal signs or hemodynamic instability. The patient remained stable, and symptoms resolved without surgical intervention. Follow-up imaging and endoscopic evaluation revealed no abnormalities.

This case highlights a rare presentation of spontaneous pneumoperitoneum in a non-intubated, oxygen-independent patient with COVID-19. Proposed mechanisms include viral-induced mucosal disruption, microthrombi-related ischaemia, and air translocation across fascial planes. The absence of obstructive radiographic features supported conservative management. Plain radiography played a central role in diagnosis and monitoring. Spontaneous pneumoperitoneum may occur in patients with mild COVID-19 without barotrauma or perforation. In the absence of clinical deterioration or obstructive features, conservative management guided by imaging is a safe and effective approach. Awareness of this entity is crucial to avoid unnecessary surgical interventions.