Recurrent valvular pneumoperitoneum caused by a minute gastric ulcer--a case report

A rare case of valvular pneumoperitoneum is reported. A 49-year-old Japanese man underwent an emergency laparotomy under a tentative diagnosis of perforating panperitonitis on the 19th post-open heart surgery day. A large volume of free intraperitoneal gas was revealed, but no identification of gastrointestinal perforation. On the 17th postlaparotomy day, pneumoperitoneum recurred. On the 41st postlaparotomy day, a tiny gastric perforation was detected with an oral contrast medium. The patient died of liver failure due to serum hepatitis. The autopsy revealed a minute gastric ulcer scar 2 mm in diameter in the mucosa of the fornix, which was thought to have caused the valvular pneumoperitoneum. A literature review was made of 8 reports on 11 cases. In two cases of valvular pneumoperitoneum, the perforating site could not be found even during laparotomy. It is suggested that either gastrointestinal series or endoscopy must be carefully repeated in order to identify the perforating site.