The Silent Abdomen: The Conservative Management of Large Idiopathic Pneumoperitoneum.

Pneumoperitoneum is typically considered a sign of gastrointestinal perforation requiring emergency surgery. However, benign or idiopathic pneumoperitoneum can occur without peritonitis or systemic illness and may be managed without surgery. We report the case of an 82-year-old male with an incidentally discovered large-volume pneumoperitoneum (estimated at 2.2 litres) on imaging, despite the absence of abdominal pain, fever, or peritoneal signs. A CT scan with oral contrast demonstrated no evidence of perforation, and the patient remained clinically stable throughout admission. He was treated conservatively with antibiotics and bowel rest, achieving a full recovery without surgical intervention. This report highlights the importance of distinguishing benign or idiopathic pneumoperitoneum from true surgical emergencies, because in selected patients with reassuring clinical and radiological findings, conservative management may be a safe and effective alternative to unnecessary surgical exploration.