8 A Curious Case of Air Without Agony: Asymptomatic Occult Viscus Perforation Post Fall - A Case Report

Abstract Introduction Hollow viscus perforation (HVP) is a life-threatening surgical emergency. Classical presentations include acute abdominal pain and peritonitis; however, elderly patients often present atypically due to physiological changes associated with aging. Pneumoperitoneum without identifiable cause on imaging further complicates diagnosis and management. This case highlights the need for clinical vigilance in elderly patients presenting with incidental findings of free intraperitoneal air. Case presentation A 103-year-old male presented to the Emergency Department after a mechanical fall. He was hemodynamically stable and denied abdominal pain or other gastrointestinal symptoms. CT imaging performed as part of trauma evaluation revealed pneumoperitoneum with no clear source of perforation. Severe sigmoid diverticulosis was noted. Due to the absence of peritoneal signs and the patient’s stable condition, conservative management was initiated. He was treated with nil by mouth, intravenous fluids, proton pump inhibitors and antibiotics. The patient remained clinically stable and was discharged without surgical intervention. Clinical discussion This case underscores the diagnostic challenge of silent HVP in geriatric patients. While CT imaging is highly sensitive for detecting pneumoperitoneum, it may not always identify the perforation site, especially in cases with sealed or micro-perforations. Conservative management can be safe in carefully selected patients, particularly the elderly, where surgical risk is high. Conclusions In asymptomatic elderly patients with pneumoperitoneum, a conservative approach may be appropriate. This case supports individualised, judgement-driven management, emphasising the importance of clinical correlation in the absence of radiologically confirmed perforation.