Spontaneous Recurrent Pneumoperitoneum in Systemic Sclerosis

atory laparotomy when he was 71 years old due to pneumoperitoneum with no identifiable cause. Other regular medications, smoking, or alcohol consumption were also denied. Family history was irrelevant. On admission, the patient was stable and without fever; the abdomen was markedly distended, with decreased bowel sounds, diffuse tympanism, and tenderness but without peritoneal signs. Blood tests showed no significant abnormalities. Standing chest and abdominal radiographs revealed free air under both hemidiaphragms, distension of the small and large intestine, and air-fluid levels ( Fig. 1, 2 ). Abdominal and pelvic contrast-enhanced computed tomography confirmed the presence of pneumoperitoneum and showed many distended loops of the small bowel, but no cause of the free air was identified ( Fig. 3, 4 ). The patient’s general condition was stable, and antibiotics, analgesics, and promotility agents were started. Despite the absence of other causes and due to the chronic presentation, pneumoperitoneum was considered a manifestation of systemic sclerosis. The patient was discharged on day 7 with symptomatic medication (butylscopolamine, domperidone, and simethicone). Six months later, abdominopelvic computed tomography was repeated and revealed a smaller pneumoperitoneum and the presence of small air bubbles in the colonic wall; no obstructive lesion was identified. The symptoms improved with oral medication. One year later, magnetic resonance enterocolonography showed mild pneumoperitoneum, normal contrast progression, and distension of the small intestine; there were no stenotic lesions, fistulas, or contrast extravasation into the pneumoperitoneum. At outpatient follow-up 24 months later, the patient had recurrent mild abdominal distension but remained clinically well. In this case, the most suitable cause of the nonsurgical recurrent pneumoperitoneum was systemic sclerosis. Key Words