Spontaneous pneumoperitoneum and diabetic ketoacidosis in fulminant type 1 diabetes: a case report

A 41-year-old woman was referred to our emergency department with a 3-day history of upper abdominal pain. We diagnosed her with diabetic ketoacidosis (DKA) after laboratory tests indicated a blood glucose level of 569 mg/dL, positive urine ketone bodies and metabolic acidosis. Plain computed tomography (CT) scan revealed free gas surrounding the porta hepatis and gastric pylorus, which disappeared on the subsequent contrast-enhanced CT scan. Upper gastrointestinal endoscopy demonstrated no perforations; therefore, we assumed that the free gas was caused by spontaneous pneumoperitoneum. The patient had fulminant type 1 diabetes mellitus, as evidenced by her glycated hemoglobin A1c level of 6.9%, reduced insulin secretion and negative islet-specific autoantibodies. Pneumoperitoneum did not recur with conservative treatment, and DKA improved with intravenous fluids and insulin administration. Conservative management of DKA with spontaneous pneumoperitoneum may be considered if the patient's general condition is stable and there are no signs of peritoneal irritation.