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However, emerging reports have described pneumoperitoneum without surgically meaningful bowel injury, raising concerns about unnecessary operations. This systematic review and meta-analysis aimed to quantify the proportion of patients with blunt trauma with computed tomography (CT)-detected FIA who had no significant bowel perforation, defined as either (1) non-therapeutic laparotomy with no identified macroscopic perforation or (2) successful nonoperative management without subsequent clinical deterioration.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      This review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42020202174). PubMed, Embase, Scopus, and Web of Science were searched through November 13, 2025, for observational studies reporting the outcomes of patients with blunt trauma with CT-detected FIA. Two reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle\u2013Ottawa Scale. A random-effects meta-analysis was performed to estimate the pooled proportion of FIA cases without significant perforation. Heterogeneity was assessed using I-squared statistic (measure of heterogeneity) and \u03c4\n                      <jats:sup>2<\/jats:sup>\n                      ; small-study effects were examined using contour-enhanced funnel plots and Egger\u2019s regression. Case reports meeting eligibility criteria were narratively summarized.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Fourteen studies comprising 8,972 patients with blunt trauma were included. Among them, 239 (2.7%) had CT-detected FIA. In the FIA subgroup, 117 patients (49.0%) had surgically confirmed bowel perforation, whereas 122 (51.0%) had no significant perforation, defined as a non-therapeutic laparotomy or a stable nonoperative clinical course. Among patients without FIA on CT, 56 of 8,733 (0.6%) had bowel perforation identified during surgery. The pooled analysis showed that 34% (95% CI 14\u201363%) of patients with FIA had no significant perforation. Substantial heterogeneity was observed (I-squared statistic\u2009=\u200980.3%, \u03c4\n                      <jats:sup>2<\/jats:sup>\n                      \u2009=\u20093.26,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), reflecting variations in CT acquisition, diagnostic criteria, and operative thresholds. Funnel plot asymmetry suggested potential small-study effects. Additionally, 19 case reports (20 patients) published between 1999 and 2025 illustrated that benign pneumoperitoneum most often occurred in young men following high-energy trauma, commonly associated with pneumothorax or pneumomediastinum; most underwent nontherapeutic laparotomy, whereas several were successfully managed nonoperatively.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>A noteworthy subgroup of patients with blunt trauma with CT-detected FIA did not exhibit clinically significant bowel perforations. Although FIA remains an important radiologic warning sign, it is not an independent diagnostic indicator of significant hollow viscus injury. Clinical decision-making should integrate clinical assessment with adjunctive CT findings rather than rely on FIA alone. Owing to the rarity of FIA and limited sample sizes, larger prospective studies are required to refine the diagnostic performance of FIA and optimize selective nonoperative management strategies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1186\/s13017-026-00673-3","type":"journal-article","created":{"date-parts":[[2026,2,1]],"date-time":"2026-02-01T10:15:56Z","timestamp":1769940956000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Pneumoperitoneum without significant bowel perforation in patients with blunt trauma: a systematic review and meta-analysis"],"prefix":"10.1186","volume":"21","author":[{"given":"Emad","family":"Masuadi","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasir Ahmed Mohammed","family":"Elhadi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Osman S.","family":"Abdelhamed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zainab M.","family":"Alkharas","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda","family":"\u00d6stlundh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gamila","family":"Ahmed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashraf F.","family":"Hefny","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,1]]},"reference":[{"key":"673_CR1","doi-asserted-by":"publisher","DOI":"10.1136\/ADC.2005.089789","author":"H Williams","year":"2006","unstructured":"Williams H. 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Accessed 9 Oct 2025"}],"container-title":["World Journal of Emergency Surgery"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s13017-026-00673-3","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13017-026-00673-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s13017-026-00673-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T10:32:46Z","timestamp":1772447566000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1186\/s13017-026-00673-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,1]]},"references-count":45,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,12]]}},"alternative-id":["673"],"URL":"https:\/\/doi.org\/10.1186\/s13017-026-00673-3","relation":{},"ISSN":["1749-7922"],"issn-type":[{"value":"1749-7922","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,1]]},"assertion":[{"value":"26 October 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 January 2026","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"1 February 2026","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was based exclusively on previously published data and did not involve direct patient participation. Ethics approval was not required. The study protocol was registered with the International Prospective Register of Systematic Reviews (ID: CRD42020202174).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Case reports included in this review were extracted from previously published studies. Patient consent for publication was obtained by the original authors. Therefore, additional consent for publication was not required for the present study.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"11"}}