Tension Pneumoperitoneum: A Comprehensive Review of Etiologies, Diagnosis, and Management Strategies

Tension pneumoperitoneum (TPP) is a rare but life-threatening condition characterized by free intraperitoneal air causing intra-abdominal hypertension and hemodynamic compromise. It shares physiologic features with abdominal compartment syndrome and requires timely recognition and intervention. This systematic clinical review evaluates the presentation, diagnostic strategies, management approaches, and outcomes associated with TPP.

A comprehensive literature search was conducted across PubMed, EMBASE, and Google Scholar for studies published between 2004 and 2024. Search terms included "tension pneumoperitoneum," "acute pneumoperitoneum," "surgery," and "needle decompression." Eligible studies included human case reports, case series, and narrative reviews that addressed the pathophysiology, diagnosis, or management of TPP. Duplicates were removed and a two-step screening process was used to identify studies for inclusion. A total of 78 studies were selected, including 57 patient cases for subanalysis.

Of the 57 cases identified, 40 involved adults and 17 involved pediatric patients. The overall survival rate was 84.2% with higher survival observed in the pediatric population (94.1% vs. 80%). Iatrogenic causes were the most common etiology accounting for 56.1% of cases followed by medical (24.6%), traumatic (14%), and idiopathic (5.3%) inciting events. Management strategies included percutaneous decompression alone (26.3%), operative intervention alone (29.8%), combined decompression and surgery (28.1%), and endoscopic management (7%). Non-procedural management was infrequently reported (8.8%).

This comprehensive clinical review emphasizes that successful treatment of TPP occurs through early recognition, understanding the variability of precipitating events, and individualized management. Heightened awareness and diagnostic vigilance may decrease delay in diagnosis and minimize associated morbidity and mortality.