Barotrauma-Related Pneumoperitoneum in a Ventilated Child: Distinguishing Air Leak From Bowel Perforation.

Pneumoperitoneum in a mechanically ventilated neonate often raises the suspicion of an acute surgical abdomen. However, barotrauma-related pneumoperitoneum resulting from alveolar rupture and air dissection into the peritoneal cavity can mimic gastrointestinal perforation. Differentiating this rare complication of positive-pressure ventilation from a true viscus perforation is essential to prevent unnecessary surgical intervention. We report a two-month-old infant born prematurely with a history of intraventricular hemorrhage and patent ductus arteriosus who presented with frequent apneic episodes, requiring mechanical ventilation at high airway pressures. Serial chest and abdominal radiographs revealed free air under the diaphragm, suggesting pneumoperitoneum. Despite radiographic evidence of potential bowel perforation, the infant remained hemodynamically stable with a soft, non-tender abdomen. A percutaneous peritoneal drain was placed for decompression, but subsequent imaging showed a right-sided pneumothorax requiring chest tube placement. An upper gastrointestinal contrast study confirmed normal bowel continuity with no evidence of perforation, supporting a diagnosis of ventilator-induced pneumoperitoneum. Conservative management-adjusting ventilator settings to reduce peak pressures and maintaining peritoneal drainage-achieved complete resolution of the pneumoperitoneum without surgical exploration. Barotrauma-induced pneumoperitoneum is an important consideration in ventilated infants who develop free intraperitoneal air. Timely recognition and a conservative approach are often sufficient when clinical and radiological findings exclude gastrointestinal perforation. Prompt diagnosis and careful ventilator management can prevent unnecessary laparotomies and optimize outcomes for these vulnerable patients.